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Elements of Pediatrics 

for 
Medical Students 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



Elements of Pediatrics 

for 

Medical Students 



BY 
ROWLAND GODFREY FREEMAN, A.B., M.D. 

Adjunct Professor of Pediatrics New York University and Bellevue 

Hospital Medical School; Attending Pediatrist to The Roosevelt 

Hospital, New York, etc. Ex-President of The American 

Pediatric Society 



Sfom fork 

THE MACMILLAN COMPANY 

1917 



All rights reserved 



1? <3"4S- 
,4= .7 



Copyright, 1917 
By THE MA.CMILLAN COMPANY 

Set up and electrotyped. Published November, 1917. 



m -8 1917 



0CU476982 



PREFACE 

The study of Pediatrics has developed rapidly and 
has not yet assumed a reasonable or logical form. 
The fact that infants differ from adults in various 
points of anatomy, physiology, pathology, diagnosis 
and treatment is too little appreciated, so that works 
on pediatrics are still published which are devoted 
almost entirely to the diseases of infants and children 
with little or no information regarding the charac- 
teristics of children or of that part of pediatrics 
which occupies a large portion of the time of most 
pediatrists, the problem of keeping infants and chil- 
dren well by proper regime and feedings. 

It is the aim of this book to impart these facts in a 
simple and concise form, and in addition to sum- 
marise the important facts to be obtained by physical 
examination, by examination of the urine and feces 
and by Roentgen-ray examination and review briefly 
the essentials of diagnosis and treatment. The au- 
thor believes that the information it contains is of 
the sort that should be made familiar to medical stu- 
dents before they take up the study of the diseases 
of infancy and childhood. 

The author wishes to express his indebtedness to 
Professor William Perry Northrup, to Professor Ed- 
win Bradford Cragin, to Professor Francis Carter 
Wood, and to Doctor Oscar M. Schloss for valuable 



PEEFACE 

suggestions ; also to Doctor Anthony C. Freeman for 
aid in preparing the Chapters on "Urinary Anal- 
ysis/ ' and "Examination of the Feces"; and to Miss 
Nina A. Brown for the preparation of the illustra- 
tions, proofreading and the making of the index. 



TABLE OF CONTENTS 

CHAPTER PAGE 

I Anatomy of the New Born 1 

II Physiology of the New Born 12 

III Development 15 

IV The Care of the Healthy Infant .... 57 

V The Care of the Infant During the First Day 63 

VI The Care of the Infant During the Second 

Day 73 

VII Nursery Hygiene . 75 

VIII Daily Regime 102 

IX Vaccination 109 

X Typhoid Immunisation 115 

XI Feeding During the First Year 117 

XII Weaning 134 

XIII Wet Nursing 138 

XIV Mixed Feeding 141 

XV Artificial Feeding 144 

XVI The Modification of Milk 154 

XVII The Pasteurisation of Milk 168 

XVIII Methods of Artificial Feeding 176 

XIX Theory of Infant Feeding 197 

XX Elimination of Bottle Feeding 204 

XXI Care of Premature Children 210 

XXII Mental Development of Children .... 215 



TABLE OF CONTENTS 

CHAPTER PAGE 

XXIII The Moral Development and Control of Chil- 

dren 218 

XXIV Physical Examination 221 

XXV Urinary Analysis 229 

XXVI Examination of the Feces 240 

XXVII Examination by Roentgen-Ray 245 

XXVIII Diagnosis .247 

XXIX Treatment * . 252 



LIST OF ILLUSTRATIONS 

FIGURE PAGE 

1. Comparison of Infant at Birth with Adult .... 1 

2. Foetal Circulation 3 

3. Weight Chart of the First Week 17 

4. Weight Chart of the First Year 18 

5. Weight Chart of an Artificially Fed Child .... 20 

6. Weight Chart of a Nursed and Artificially Fed Child . 21 

7. Weight Chart During the First Year of Well-cared-for 

Children Compared with Institution Children ... 23 

8. Weight Chart During the First Twelve Years of Well- 

cared-for Children Compared with Other Children . 25 

9. Weight and Height of Boys and Girls from Birth to 

Sixteen Years 26 

10. Chart Showing That Loss of Weight Is an Important 

Indication of Approaching Illness 28 

11. Average Height of Children During the First Year . . 29 

12. Length of Children of the Same Weight at Different 

Ages 31 

13. Head and Chest Circumference at Different Ages . . 33 

14. Comparison of Skull of an Infant at Birth with the 

Skull of an Adult 35 

15. Spinal Curves 36 

16. The Increase in Weight of Certain Organs During In- 

fancy and Childhood 38 

17. First Dentition 40 

18. Second Dentition 42 

19. Stomach Capacity 48 

20. Daily Secretion of Urine at Various Ages .... 55 

21. Death Rate of Infants Under One Year in Various 

Countries 58 

22. Deaths of Infants and Children by Months in New York 59 

23. Clothing of Babies 69 

24. Analysis of Human Milk and Colostrum 71 

25. Breck Feeding Tube 72 



LIST OF ILLUSTRATIONS 

FIGURE PAGE 

26. Proper Scales for Weighing" Babies 80 

27. Daily Regime of a Baby Under Three Months . . . 103 

28. Daily Regime of a Child from Three to Six Months . . 103 

29. Daily Regime of a Child from Six Months to One Year 104 

30. Daily Regime of a Child in Its Second Year . . . 105 

31. Daily Regime of a Child After the Second Year . . .107 

32. Vaccination 112 

33. Classification of Infant Feeding 118 

34. Apparatus for Examination of Breast Milk .... 124 

35. Plate Showing Origin of Milk Contamination . . . 148 

36. Analysis of Cow's Milk .... 151 

37. Mineral Matter in Milk 152 

38. Chapin Dipper 162 

39. Fat Content of the Different Layers of a Quart Bottle 

of Milk 162 

40. Sugar of Milk Graduate 166 

41. Sanitary Nursing Bottle 166 

42. Thermal Death Point in a Moist Medium of Certain 

Pathogenic Bacteria 169 

43. The Effect of Heat on Certain Biologic Characteris- 

tics of Milk 170 

44. Pasteuriser 173 

45. Temperatures during Pasteurisation of a Bottle of Milk 174 

46. Examples of Feedings for the First Year . . . .178 

47. Laboratory Feeding Prescription 183 

48. Analysis of Barley Water 185 

49. Feeding Chart 198 

50. Feeding Chart 199 

51. Feeding Chart 200 

52. Feeding Chart 201 

53. Feeding Chart 202 

54. Analysis of Beef Juice and Beef Broth 205 

55. Weight and Length of Foetus in Utero 211 

56. Incubator 212 

57. Apparatus for Schmidt's Fermentation Test . . . 243 

58. Diagnosis Chart 248 



ELEMENTS OF PEDIATRICS 



CHAPTER I 



ANATOMY OF THE NEW BOKN 



Characteristics of in- 
fant. — On examining a 
healthy infant, having 
in mind the adult type, 
one is immediately im- 
pressed with certain 
marked characteristics. 
(Figure No. 1.) The 
infant has a very large 
head and a small face, 
and apparently, al- 
though not really, a 
short neck, a rather 
small thorax in contrast 
with a large protruding 
abdomen, a very slightly 
developed pelvis and 
small legs. For an ex- 
planation of these pe- 
culiarities, which are 
most marked at birth, 
one has to consider the nourishment of the child in 
utero. 

l 




Infant at Birth Adult 

FIGURE 1. 

Comparison of Infant at Birth 

with Adult. 



2 ELEMENTS OF PEDIATRICS 

Foetal circulation. — The foetus in utero is supplied 
with oxygen, as well as nourishment, from the pla- 
centa by means of the circulation of its blood through 
the placenta, where it obtains from the blood of the 
mother the nourishment it requires. (Figure 2.) 

The vessels that carry the blood of the f cetus to and 
from the placenta are three: the two umbilical ar- 
teries carry blood to the placenta ; while the umbilical 
vein passes from the placenta along the umbilical 
cord, carrying this fresh placental blood to the liver, 
where it divides into three branches, two of these 
supplying the liver, while the third, the ductus 
venosus, carries the blood to the inferior vena cava 
and thus to the right auricle of the heart. Here it 
does not pass into the right ventricle, as in the adult, 
but by means of the Eustachian valve this blood cur- 
rent is directed through the foramen ovale to the left 
auricle, from which it flows into the left ventricle, 
being forced from there into the aorta. This placen- 
tal blood, then, is supplied to the liver and to the 
head and upper extremities by means of the aorta, 
while before it reaches the descending aorta, it is 
mixed with blood from the right side of the heart. 

The portion of this blood which passes through the 
carotid and subclavian arteries to the head and upper 
extremities returns to the superior vena cava, passes 
into the right auricle and right ventricle, and is 
forced by the contractions of the ventricle into the 
pulmonary arteries, from which by means of the duc- 
tus arteriosus a considerable portion of it passes 
into the descending aorta, reaching, through the in- 




FIGURE 2. 

Diagram of the Circulation of the Foetus Indicating the Parts 
that Disappear After Birth. 



A. Umbilical Vein. 
D. Foramen Ovale. 



B. Ductus Venosus. C. Eustachian Valve. 

E. Ductus Arteriosus. F. Umbilical Arteries. 



4 ELEMENTS OF PEDIATEICS 

ternal iliac and umbilical arteries, the umbilical cord 
and placenta. 

Respiration. — During the period of intra-uterine 
life, then, the lungs are solid organs ; and the heart 
has the Eustachian valve and the opening of the fora- 
men ovale between the auricles. It is thus evident 
that at birth very radical changes must take place in 
order that the infant may still obtain the necessities 
for life. The placental nourishment is cut off and 
the child gasps for breath. This air passes through 
the mouth, pharynx, larynx, and bronchi, and must 
be drawn into the lung, at this time practically a 
solid organ. With many infants breathing is at first 
difficult and insufficient, and only after considerable 
assistance through counter-irritation, the application 
of heat or cold, or the use of artificial respiration, is 
a sufficient function of the lungs established. 

Changes in the heart after birth. — With the estab- 
lishment of the function of the lungs the usefulness 
of the foetal appendages of the heart is passed, so 
that the Eustachian valve disappears, the foramen 
ovale gradually closes, the ductus venosus becomes a 
fibrous cord in from four to ten days, the umbilical 
vein becomes the round ligament of the liver in from 
two to five days, while the umbilical arteries form the 
anterior true ligaments of the bladder. A study of 
the foetal circulation, then, shows us one reason why 
the moment of birth is a critical moment for the 
infant ; why some parts of the body, such as the head 
and liver, receiving a better blood supply, should 
become more developed during intra-uterine life than 



ANATOMY OF THE NEW BORN 5 

others, and it also shows us the direction that will 
be taken by navel infections in infancy; in such 
cases the umbilical vein is sometimes found rilled 
with pus. 

Proportions of infant body in comparison to adult. — 
As will be seen by reference to the chart (Figure 1) 
the large head of the infant occupies about one-fourth 
of its stature, while in the adult the line dividing off 
the upper fourth of the body passes through the 
axillary line, and the head occupies about one-eighth 
of the stature. Again the middle line of the body 
which in the child at birth passes just above the um- 
bilicus, in the adult is much lower, at about the level 
of the crest of the ilium. The trunk, Dr. Rotch has 
well said, resembles somewhat the shape of an egg; 
the large end of the egg represents the lower part of 
the body, the shoulders being attached to the smaller 
end. 

Appearance. — Healthy babies at birth should have 
a bright red color and should be plump with a fairly 
thick layer of adipose tissue below the skin. 

Sebaceous glands. — The sebaceous glands of the 
skin are well developed at birth and this is evident 
from the large amount of vernix caseosa, the excre- 
tion of these glands, which is often found on the body 
of the child at birth. 

Sweat glands. — The sweat glands are not well de- 
veloped. 

Weight. — These stocky little bodies should weigh 
about seven pounds at birth, but this weight may vary 
from six to nine pounds or more, depending on the 



6 ELEMENTS fOF PEDIATEICS 

length of the body and the state of nourishment, these 
conditions again depending on the size and health of 
the parents and the duration of intra-uterine life. 

Length. — The length of the body should be about 
twenty inches; the circumference of the head thir- 
teen and one-half inches, that of the thorax thirteen, 
and that of the abdomen about fourteen inches. 
This latter measurement is very variable, depending 
to a considerable extent on the distention of the in- 
testines with gas at the time the measurement is 
taken. 

Navel wound. — One of the greatest dangers to the 
infant is its first wound, the severed cord, which if 
allowed to remain moist or if contaminated by an 
invasion of bacteria may lead to an infection which 
sometimes speedily ends life. The navel should be 
healed in about five days. 

Skeleton. — The skeleton of these babies is very in- 
completely developed. 

Skull. — The bones of the skull have not united so 
that during birth they are pressed together and often 
overlap. Four considerable openings exist, dimin- 
ishing in size in the order named : the anterior f on- 
tanelle (Figure 14), the largest, is at the junction of 
the frontal and parietal bone and is usually about an 
inch in lateral diameter and two inches in longitudi- 
nal diameter; the posterior fontanelle, at the junc- 
tion of the occipital bone with the two parietal bones 
in the median line at the back of the head is usually 
sufficiently open to be felt, as are also the two lateral 
fontanelles at the junction of the occipital, parietal 



ANATOMY OF THE NEW BOEN 7 

and temporal bones, and so long as the sign known as 
cranio-tabes — the depression of the bones of the skull 
over the lateral f ontanelle on pressure by the fingers 
— is present it may be assumed that this closure is 
not complete. When one considers the very deficient 
ossification of the skull and the fact that the two 
frontal bones are never completely united, that the 
frontal and parietal, parietal and temporal, and the 
parietal and occipital, as well as the two parietal 
bones have no bony connection, being joined by mem- 
brane only, it is evident that the brain is but slightly 
protected, and that the skull may easily be unduly 
compressed by tight bandaging or its shape altered 
if the child is allowed to lie continuously on one 
side. 

Spinal column. — The spinal column is largely car- 
tilaginous and very flexible, so that when cut away 
from the ribs it may readily be bent in all directions. 
It, moreover, has but one curve with its convexity 
backward. Thus abnormal curvatures may result 
from fairly slight causes. 

Head. — We have noticed that the head of the child 
is very large, in fact, occupying one-fourth the length 
of the body instead of one-eighth as in the adult, and 
this is due to the large size of the brain, which often 
weighs three-fourths of a pound, that is one-ninth 
of the total weight of the child. It is thus five times 
as large in proportion to the body weight as in the 
adult. The dura mater is quite adherent to the 
bone. 

The face. — The face of the infant at birth is very 



8 ELEMENTS OF PEDIATRICS 

small, being only one-eighth as large as the cranium 
and this small size is due to the fact that the nose and 
alveolar process of the maxillary bones are but little 
developed. The walls of the cheeks are thickened by 
large pads of fat, which render them more resistant 
and thus of service in sucking. 

Nasal cavity. — The nasal cavity is small, particu- 
larly the post-nares, so that this is easily occluded by 
inflammatory processes. Moreover, in this post- 
nasal pharynx there exists a mass of lymphoid tissue 
known as the third tonsil or adenoid, which is of con- 
siderable importance in children, because in certain 
climates it very commonly becomes enlarged, giving 
rise to symptoms, often very early in life, which if 
persistent necessitate its removal. 

The mouth. — The mouth is somewhat drier than in 
adults, due to the slight development of the salivary 
glands, and the tongue is proportionately smaller. 
While no teeth are to be seen, the twenty teeth of 
the first set are present in the sacs of the alveolar 
process of the superior and inferior maxillary bones. 
These are covered by mucous membrane and do not 
usually begin to pierce this membrane until after the 
sixth month. 

The eye. — The eye at birth is a perfect organ, the 
poor perception of these infants being due probably 
to insufficient brain development. The lachrymal 
glands are inactive, so that when these young babies 
cry they shed no tears. The orbital plate of the 
frontal bone is very thin, offering little resistance 
to foreign bodies brought in contact with it. 



ANATOMY OF THE NEW BOEN 9 

The ears. — The ears at birth are in part well devel- 
oped, but the mastoid cells are not well developed 
until after puberty, although inflammation of the 
mastoid often occurs in early life. 

The neck. — The neck of the child is really propor- 
tionately longer than in adults, the apparent short- 
ness being due to adipose tissue under the chin 
and above the clavicle. Between the muscles of the 
neck there are a large number of lymph nodes 
which, though rarely noticeable at birth, are often 
the seat of enlargement in babies and young chil- 
dren. 

Thymus gland. — The thymus gland, which is sit- 
uated behind the upper part of the sternum, often com- 
ing down well over the pericardium, is a conspicuous 
organ at this period and important because children 
in whom it is enlarged seem particularly liable to 
sudden death, this enlargement being associated with 
the condition known as lymphatic constitution. 

The heart. — The heart of the baby at birth is pro- 
portionately somewhat larger than in the adult and 
occupies a considerable portion of the thoracic cavity, 
its weight being about six drachms. 

The lungs. — The lungs, even when well aerated, 
differ materially from the adult lungs. The bronchi 
are larger and more numerous; the air cells are 
much smaller; the interstitial tissue much more 
abundant. These facts are important in connection 
with the respiratory diseases of infants and young 
children, which differ in type from those found 
in adults. The pneumonia of infants is usually 



10 ELEMENTS OF PEDIATEICS 

broncho-pneumonia instead of lobar pneumonia, 
which commonly occurs in adults. 

The diaphragm. — The diaphragm, which plays a 
comparatively more important part in respiration in 
babies than in adults, is well developed and occupies 
a higher position. 

The abdomen. — The abdomen is prominent in 
babies, owing to the large size of the liver, as well as 
to the small size of the pelvis. 

The liver. — The liver, as already stated, is very 
large, weighing about three ounces six drachms, or 
nearly one-fourth of a pound, that is one-twenty- 
eighth as much as the body weight instead of one- 
thirty-seventh as in the adult ; it contains much more 
fat than is contained in the liver of adults. 

The kidneys. — The kidneys also are of a relatively 
large size and frequently contain infarctions of uric 
acid, which cause red stains on the diapers. 

The bladder. — The bladder owing to the small size 
of the pelvis, is in the new born an abdominal organ, 
and when distended is readily palpable. 

Stomach and intestines. — The stomach and intes- 
tines vary in form and position from that of the 
adult, these variations being due to the type from 
which they are developed. In early fetal life the 
alimentary tract is a straight tube which, with growth 
in length, becomes doubled upon itself. Thus, the 
stomach, as would be expected, occupies a more ver- 
tical position than in the adult and is more tubular, 
the fundus of the stomach being but slightly devel- 
oped. The caecum is in infancy very movable, and 



ANATOMY OF THE NEW BORN 11 

the appendix may be found in an infant at birth any- 
where between the liver and the region of the rectum, 
although usually it is found in the right iliac fossa. 

Weight of viscera. — In Figure 16 is shown the 
weight of the principal viscera at birth and to the 
fourteenth year. All the viscera are heavier at birth 
in proportion to the weight of the body than in 
adults. This is most marked in the brain which in 
infants is more than one-tenth of the body weight, 
while in adults it is about one-fiftieth. Next in 
order comes the liver, the kidneys, the heart, while 
the lungs and spleen are only slightly heavier in 
proportion to the body weight than in the adult. 



CHAPTER II 

PHYSIOLOGY OF THE NEW BORN" 

Vitality. — New born babies exhibit a degree of vi- 
tality which is somewhat proportionate to their 
weight. A well developed child of fair weight who 
is properly managed from birth usually gives little 
trouble. 

A baby of four or five pounds has very poor vi- 
tality and needs special treatment; a baby of seven 
pounds has normal vitality; while one of eight or 
nine pounds has a high degree of vitality. 

As soon as a new born child has established a good 
respiratory function, it should become quiet and 
sleepy. It should sleep practically all the time ex- 
cept when being fed; any deviation from this con- 
dition is an evidence of some abnormality. Al- 
though the eyes may open and close, the vision ap- 
parently makes little impression on the brain. 
When uncomfortable the infant will cry out. 

The rectal temperature is normally about ninety- 
nine degrees Fahrenheit; the pulse varies from one 
hundred and twenty to one hundred and forty, 
while the respirations are rather rapid, varying 
from forty to sixty or seventy per minute. The 
respirations are also very irregular, the child breath- 
ing quickly for a time and then again slowly. The 

12 



PHYSIOLOGY OF THE NEW BOEN 13 

normal relation of respirations to pulse of one to 
four is not present in the new born but is established 
soon after birth. 

Salivary glands. — The salivary glands of the new- 
born, as has already been stated, produce but little 
secretion. This, however, has power to decompose 
starch. The secretion is increased after the second 
month and markedly so after teething. 

Digestion. — The stomach takes but little part in 
digestion of food in the infant, but provides a 
reservoir into which the milk is received and from 
which it passes quickly into the intestines. Pepsin 
is, however, found in the stomach at birth, as is free 
hydrochloric acid ; a fat splitting ferment is also said 
to be present. Protein is transformed into acid 
albumin, albuminose and peptone. 

Pancreas. — The pancreas is fairly developed, but 
its secretion probably has little amylolytic action. 

Bile — Meconium. — Bile and bile salts are secreted 
and pass into the intestines during intra-uterine life, 
and these, together with desquamated epithelium and 
other material, form the meconium which is con- 
tained in the intestines at birth and which is grad- 
ually expelled during the first day or two of life. 
The total amount of this meconium contained in the 
intestine at birth is two or three ounces. 

Urine. — The activity of the kidneys begins at birth. 
The amount of urine secreted during the first two 
days of life is small and the urine has a high specific 
gravity of about 1015 to 1020. 

Blood. — The blood of the new born shows varia- 



14 ELEMENTS OF PEDIATRICS 

tions from the adult type. It contains about six 
million red blood corpuscles in each cubic millimeter 
while the white corpuscles are proportionately much 
more numerous during the first two days than in 
the adult, being about eighteen thousand to the cubic 
millimeter, but after the third day they are about the 
normal adult number. 

The haemoglobin is very high during the first 
week. It gradually drops from 23 grams per 100 c.c. 
of blood, so that by the latter part of the first year it 
reaches only 12-13 grams per 100 c.c. of blood, it 
then gradually increases until about the fifteenth 
year when it is about 16 grams per 100 c.c. of blood 
at which amount it continues during adult life. 



CHAPTER III 

DEVELOPMENT 

Weight as a standard of development. — The proper 
development of an infant dnring the first year may be 
measured by various standards, but there is no indi- 
cation more significant than the increase of weight. 

Charting weight. — The value of careful and fre- 
quent observation of the weight of a child and its 
record on a chart can hardly be overestimated. So 
important is this that at most institutions every in- 
fant at birth, or on admission, is carefully weighed 
and its weight recorded on a chart, on which subse- 
quent regular weighings are recorded, so that the 
physician in charge can always see at a glance the 
condition of nutrition of the child throughout its life 
in the institution. In private practice such records 
should never be neglected. 

Relation of weight to length. — It might be as- 
sumed that a growing child who does not gain in 
weight is actually losing, since its size is increasing 
without corresponding gain in weight, but this, as 
will be shown later, is to only a slight extent true, 
because a child who does not gain in weight grows 
little in length. Weight observations are of value 
in showing whether a child is getting the proper kind 
of food, a sufficient amount of food, or is thriving on 

15 



16 ELEMENTS OF PEDIATKICS 

its diet. A stationary weight for more than a week 
of an infant during the first year is always a cause 
of solicitude, while a loss of weight usually calls for 
some change in the daily regime. Sometimes this 
loss of weight is a danger signal of approaching ill- 
ness and is the earliest indication obtainable, as will 
be shown in charts. 

Gain in weight. — A child beginning life ivith a 
weight of about seven pounds should double this in 
five months, treble it in twelve months, and quad- 
ruple it in twenty-four months. A child should gain 
fourteen pounds by the end of the first year, and 
twenty-one pounds by the end of the second year, 
weighing at that time twenty-eight pounds. From 
that period the gain is slower, that of the third year 
averaging only about five pounds. 

Normal weight chart for first week. — A normal 
weight chart (Figure 3) of the first week of life 
shows a loss during the first two days of more than 
half a pound — about nine ounces — this being due to 
the loss of meconium, of urine and of evaporation 
from the surface of the body and the air passages, 
and to tissue waste, which is but little compensated 
for by food taken. 

The fourth day there is a loss of only about one 
ounce, due to the fact that by the third day some 
nourishment is usually obtained from the breasts; 
while on the fifth day, following the day on which 
the breasts are distended with milk, an actual gain 
is noted, which should persist during the remainder 
of the week. 



DEVELOPMENT 



17 



This chart, however, represents what one would 
expect in an infant the breasts of whose mother con- 
tained a normal milk supply. If there is no breast 
milk and a substitute food is supplied a very dif- 
ferent chart is often found, for it is during these 



Weight 
8 Lbs. 

14 OZ. 

12 OZ. 

10 OZ* 

8 oz. 

6 oz. 

4 oz. 

2 oz. 
7 lbs t 


Days 
I 


2 


a 


4 


5 


6 


7 


























































\ 














\ 
















\ 














\ 














\ 














\ 














\ 


k 














\ 




/ 










\ 




Y 










V 


</ 





































FIGURE 3. 
Weight Chart of the First Week. 



first days of life that it is most difficult to feed a 
child satisfactorily with any substitute food, so 
that in these cases a moderate loss, or at any rate no 
material gain, may take place for two or three weeks. 
If, as in some of these cases, there is an extreme loss 
associated with a rise of temperature, we have 



18 



ELEMENTS OF PEDIATEICS 



usually a condition known as inanition fever, which is 
believed to be due to actual starvation. With this 
condition the temperature may rise to 104° F., but 
promptly descends to normal on the administration 
of food. After the fourth day breast-fed children, 
who are born at term and are healthy, should show a 
rapid increase in weight, as may be seen on the 
chart. 

Normal weight chart for first year. — Figure 4 
shows a normal weight chart for a well cared for 



Birth 3Mos. GMos. 9Mos. l£Mos 


Lbs. 

2-1 
20 
19 
18 
17 
16 
15 
14 
IS 
12 
11 
10 
8 
6 
*l 








^ 
















^y 






y 


<* 






S 








\s 






y 


* 














/ 






j 


y 






/ 








/ 








/ 








/ 








\y 

















FIGURE 4. 
Weight Chaet of the First Year. 



DEVELOPMENT 19 

baby during the first year and is constructed from 
the average of a considerable number of cases and 
shows rather more gain than is made by children 
who are not under good conditions. It is a gain 
which can, however, usually be exceeded by careful 
regulation of the child's life. The rate of gain 
and the comparative rate of gain during the differ- 
ent quarters of the year are about what one should 
expect as an average in well cared for children. Be- 
ginning with a weight under eight pounds, with a 
loss during the first three days of ten ounces, we 
have a gain during the first three months from 
the lowest weight, of about five and one-half pounds ; 
during the second three months of about three and 
one-half pounds ; during the third three months of 
three pounds and during the fourth three months 
of about two and one-half pounds. The gain in 
weight of the first quarter of the year, therefore, 
is just equal to the gain in the last half. 

Such a chart is an average and not one that can 
be expected from any special child. Individual 
charts will have irregularities such as Figure 5, one 
of the charts from which the chart (Figure 4) was 
compiled. 

Individual weight charts. — This child (Figure 5), 
born with a weight of eight pounds, lost fourteen 
ounces in the first three days. It had little breast 
milk, and none after the eleventh day, so that it was 
thereafter a bottle fed baby. While it vomited little 
and had no colic it gained slowly, as most bottle fed 
babies do at the beginning, and it was three weeks 



20 



ELEMENTS OF PEDIATEICS 



after birth before it regained its birth weight. At 
three months it weighed 11% pounds instead of 13 
ponnds as a normal chart wonld require, but an ex- 
cellent gain for a child artificially fed from the 
eleventh day. 

When the baby was 3% months old the mother 
wished to prepare the milk at home so the cream 



AGE Birth 3 Mos. 6 Mos. 9 Mos. 13 Mos. 


POUNDS. 

22 

20 

18 

16 
14 
12 
10 
8 


















/ 








/ 








y 








y 














/ \*~y 






/ 








/ 








/ 








/ 








-r 






/ 








X 








s 








/ 








v 









FIGUKE 5. 

Weight Chart of an Artificially Fed Child Showing a Loss 
with Change in the Character of Food at 3% Months and 
Again with a Bowel Disturbance at 7% Months. 

whey mixture on which the child had previously been 
fed was abandoned and a simple modified milk was 
ordered, with no gain for more than two weeks, 
after which it gained well until at IV2 months it 
weighed 18% pounds and had cut six teeth. This 
was in August and a slight bowel disturbance and 
probably an attack of scurvy ensued so that three 



DEVELOPMENT 



21 



months later the child had only regained its lost 
weight. A period of rapid gain then ensued nntil 
the end of the first year when it weighed 22% pounds, 
1% pounds more than the average at one year. It 
had eleven teeth, and was fed full milk with the addi- 
tion of orange juice, rusk and cereal. 

A second example (Figure 6) is a breast fed baby 



AGE. Birth 3 


Mos. 6 


Uos. 9 Mos. 12 Mos. 


Pounds 23 
20 
18 
16 
14 
13 
10 
8 


























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^-^ 






y 








/ 








/ 








/ 






y 


s 






y 














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FIGURE 6. 
Weight Chart of a Nursing Baby Whose Mother Became Sick 
When He was 3% Months Old and Weaning was Completed 
at 4% Months, Followed by Five Weeks During Which 
There was no Gain in Weight. 

with a birth weight of 7% pounds and a loss to 7 
pounds 6 ounces. This child nearly regained its 
birth weight by the end of the first week and weighed 
11% pounds at three months. 

When nearly four months old the mother became 
sick and the baby began to vomit a good deal so 
that at 4% months weaning was completed and then 



22 ELEMENTS OF PEDIATRICS 

followed a period of five weeks when the feedings 
were being changed frequently and no gain in weight 
was recorded. The ensuing gain was rapid so that 
at the end of the first year the child weighed 21% 
pounds and measured 22 inches, thus being above 
the average at that time. 

These two cases show well the irregularity of most 
individual weight charts in children who do well 
eventually. 

Average charts compiled from large groups of 
children vary greatly as will be seen in Figure 7. 
In this chart the lowest line (B), made up from an 
average of 500 institution children, shows a weight 
of about one pound less than the other groups at 
one month of age, a gain of only three pounds during 
the first three months and a gain for the whole year 
of only eight or nine pounds. This may be com- 
pared with the heavy line (A) representing 120 well 
cared for children in private practice, and the two 
interrupted lines (C and D), the results obtained 
in the private practice of a German physician; the 
lower interrupted line (D) representing the result 
of artificial feeding and the upper interrupted line 
(C) that of breast feeding. This shows particularly 
well what is true in private practice, that the bene- 
fits of breast feeding are most evident during the 
first three months and after that most children do 
well on proper artificial feeding. 

Many children deprived of breast milk and not 
fitted with an assimilable food will go along many 
months without gaining. These cases often gain 



DEVELOPMENT 



23 



Months Birth 3 6 9 12 


Pounds 

22 

20 

18 

16 

14 

12 

10 

A 
c 

D 
8 














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V/fe 








V 









FIGURE 7. 
Average Weight During the First Year of 120 Well Cared for 

Children A; Compared with that of 500 Institution 

Children B; That Given by Dr. Cammerer for 119 

Breast Fed Children C; And 84 Artificially Fed Chil- 
dren in Private Practice — D. 

rapidly after obtaining* proper food but rarely weigh 
as much at the end of the first year as a child who 
does well from the start. 

It has been the custom to use weight charts with 



24 ELEMENTS OF PEDIATRICS 

the so-called normal line made from the average of 
a number of charts which, it is readily seen, is a 
great mistake, as each individual child has its own 
normal line. A seven-pound baby has a different 
normal line from a nine-pound baby. An artificially 
fed baby has a different normal line from a breast 
fed baby and a baby of large parents a different 
normal line from a baby with small parents, and 
one's estimate as to how a baby is doing should be 
based on the gain or loss in weight and not on com- 
parison with a supposed normal line. 

Failure to gain. — Any failure to gain during one 
or more weeks of the first year must usually be at- 
tributed either to illness or to improper feeding, and 
the illness may be simply the result of improper 
feeding. This fact cannot be too strongly impressed 
on parents, for one frequently sees babies who have 
been allowed to go on for months with practically 
no increase in weight and without consulting a phy- 
sician. The relation of feeding to the weight of the 
child will be considered later in the chapter on feed- 
ing. 

Average gain in weight of older children. — The 
gain in weight during the second year has already 
been stated to be an average of about seven pounds ; 
during the third year it is about five pounds, while 
in the two succeeding years- a gain of less than five 
pounds is usually recorded, then the yearly gain 
gradually increases and after the tenth year it is 
from seven to ten pounds each year in well cared 
for children as shown by the heavy black line (A), 













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26 



ELEMENTS OF PEDIATEICS 



Figure 8. In children under less hygienic condi- 
tions the gain is indicated by the dash line (B) of 
the same chart, which represents the children in an 
excellent modern orphan asylum situated in the 
country. These children average less growth than 
the very well cared for children seen in private 
practice, but do better than the children represented 
by the dotted line (C) an average of 69,000 school 
children in the United States. 



Age 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 


Founds. 
Inches. 

120 

110 

100 

90 

80 

70 

60 

50 

40 

50 

20 

10 
































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A 






























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FIGURE 9. 



A. Weight — Boys. 

B. Weight— Girls - 



C. Height— Boys. 

D. Height— Girls- 



Average Weight and Height of Boys and Girls from Birth 

to Sixteen Years. 

Compiled from more than eight thousand cases. 



DEVELOPMENT 27 

Comparison of weight of boys and girls. — Boys, as 
seen in Figure 9, are as a rule somewhat heavier 
than girls of the same age until the eleventh year, 
when the girls surpass the boys of the same age and 
remain heavier until the fourteenth year. 

Importance of weight records. — An accurate rec- 
ord of the weight is of the greatest importance to a 
physician as an indication of the exact date when 
the child ceased to thrive. The weight often serves 
as a warning that something is wrong, before any 
other symptoms of disorder arise. This is well 
shown in Figure 10 prepared from an observation 
of Bowditch. It is noticed that in the child studied 
there was a decline in weight for a month before the 
enlarged cervical glands were noticed, and more 
than five weeks before the clay coloured stools ap- 
peared. This was probably due to a subacute in- 
testinal disorder. 

In the same way a decline in a week of over a 
pound preceded the measles and still another decline 
in weight before a cold in the head was noticed. 

Moreover, during illness a good indication of the 
damage to the system is to be found in the weight 
records. Again in convalescence, when improve- 
ment is slow, the best guide as to whether or not 
the child is making satisfactory progress is to be 
found in the weight chart. If the child is gradually 
increasing in weight one may be hopeful of ultimate 
recovery. 

Height. — While a record of weight is most im- 
portant for indicating development, a record of 



CO 

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28 



DEVELOPMENT 



29 



height should also be kept, and from the relation- 
ship of weight and height an estimate of the general 
nutrition can be made. 

Growth in height. — As has already been stated, an 
infant at birth measures about twenty inches in 
length. The growth in height follows somewhat the 
same lines as the increase in weight, being more 
rapid during the first year and progressing less 
rapidly during subsequent years. 

The average growth of an infant's body during 
the first month of life is about one and three-fourths' 
inches; during the second month, one and one-half 
inches; the total growth for the first year being 
about eight inches. In private practice under good 
conditions rather better results are obtained as 
shown in Figure 11. During the second year the 
growth is but three and one-half inches and during 
the succeeding years the average growth in length 
varies from two to three inches. 



AGE. Birth 3 Mos. 


6 Mos. 


9 Mos. 


12 Mos. 


INCHES 

50 

26 

26 

24 

22 

20 


























^^-""* J 














^^ 














^^*^ 














s 








/ 








y 








s 

















FIGURE 11. 
Average Height During the First Year of 120 Well Cared for Children. 



30 ELEMENTS OF PEDIATRICS 

A corresponding difference between the growth 
in height in boys and girls to that observed in weight 
is seen in Figure 9, the average boy being somewhat 
taller than the average girl of the same age until the 
twelfth year, when the girl becomes taller than 
the boy; this condition persists until the fourteenth 
year, when the boy increases rapidly in height, ex- 
ceeding considerably the height of the girl. 

The special part of the body which grows the most 
at any particular age varies ; the trunk grows rapidly 
at first, while later on the greatest growth takes 
place in the legs. 

The increase of weight in pounds, as well as the 
increase in height in inches, for boys and girls is 
shown in Figure 9. It is noticed that these lines 
have curves in common; that where one line rises 
abruptly there is a corresponding rise in the other 
line; also that at about the fifth or sixth year the 
number of pounds a child weighs corresponds to the 
number of inches it measures. 

Growth in length of children who do not gain in 
weight. — An interesting question, which some years 
ago was entirely unsolved, is the relationship of 
weight to length in infants whose weight stands sta- 
tionary. Does a child who remains stationary in 
weight actually emaciate on account of growing 
in length? To solve this problem Dr. Fleischner 
measured and weighed five hundred children under 
one year of age and found that there was a very 
slight gain in length in children who did not gain in 
weight. This is shown well in his chart (Figure 



DEVELOPMENT 



31 



12), where it will be seen that while a nine-pound 
baby (A) one month old measures twenty-two inches 
in length, a nine-pound baby of seven months meas- 
ures only 23% inches, a gain of only 1% inches, 
while the normal gain in length during that period 



Age in Months 

12 34 5678 9 10 11 


Inches 
26 

25 

24 

23 
22 
21 
























E 






E 


















D 




D 














B 


C 








c- 

B — 












A 


































A 

















































FIGURE 12. 
A. Nine Pound Children. B. Ten Pound Children. 

C. Eleven Pound Children. D. Twelve Pound Children. 

E. Thirteen Pound Children. 
Length of Children of the Same Weight at Different Ages. 

would be six inches (Figure 11). Again a baby who 
weighs thirteen pounds at three months (E) meas- 
ures 25% inches, while a thirteen pound baby at 
eleven months measures but twenty-six inches, a gain 
of only three-quarters of an inch as compared with a 
normal gain during that period of eight months of 
some four inches. It is, therefore, important to 



32 ELEMENTS OF PEDIATBICS 

keep infants gaining in weight if one wishes them to 
have normal stature. 

Head and chest circumference. — Most important 
measurements in children are the relative meas- 
urements of the head and chest, these adding much 
information in many cases of obscure diagnosis. As 
we have seen, at birth a baby's head measures a little 
more than the thorax, which is at this age poorly 
developed. The increase in these two measurements 
is practically the same in normal children during 
the first two years. If, then, one is in doubt as to 
whether or not there is an abnormal enlargement of 
the head a comparison of the fronto-occipital circum- 
ference measurement of the head with the circumfer- 
ence of the thorax over the nipples will often give 
valuable testimony. 

The relationship between the head and chest meas- 
urements is somewhat dependent on the nourishment 
of the child, as more adipose tissue is deposited over 
the chest than over the cranium, so that while the 
head and chest circumference should be about equal 
in well nourished children, in emaciated children the 
head should measure an inch or two more than the 
chest. 

After the second year, as you will see by Figure 
13, prepared from a table by Holt, the chest meas- 
urement (B) increases more rapidly than that of the 
head (A), exceeding it by one inch at the fifth year; 
then again taking a rapid rise there is a difference of 
three inches in the sixth year, while at the tenth year 
the difference is four inches. 



DEVELOPMENT 



33 



Increase in size of face. — As we have already seen, 
the skull increases in circumference from the first to 
the eighteenth month as fast as the thorax, but at the 



laches 

30 
29 
28 
27 
26 
25 
24 
23 
22 
21 
80 
19 
18 
17 
16 
15 
14 


AGE. 
Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 


































B 
































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B 


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FIGURE 13. 

A. Head. B. Chest. 

Head and Chest Circumference at Different Ages. 

same time the face has been growing even faster, so 
that by the second year the proportion of face to 
cranium has changed considerably. At birth the 
face is only one-eighth as large as the cranium; at 



34 ELEMENTS OF PEDIATRICS 

the fifth year one-fourth ; at the tenth year one-third, 
while in the adult the proportion is as one to two and 
one-half. This increase in the size of the face is due 
to the development of the nose, the growth of the 
alveolar process, the teeth, and the development of 
the ramus of the inferior maxillary bone, and the 
change in the angle of the ramus with the body of this 
bone from an oblique angle to nearly a right angle. 
This is well shown in Figure 14. 

Ossification of bones of skull. — The ossification of 
the bones of the skull steadily increases and the pos- 
terior and lateral fontanelles disappear soon after 
birth; the anterior fontanelle in health persists, re- 
taining about the same dimensions until the tenth 
month, after which it gradually closes, so that by the 
eighteenth month or second year it should appear 
to be closed. 

Anterior fontanelle. — This anterior fontanelle is of 
great importance in diagnosis and one should remem- 
ber its normal dimensions and its time of closing. 
Moreover, while it is open, the skin covering it should 
preserve much the same level as the skin covering the 
surrounding portions of the skull, and a marked de- 
pression or bulging of this fontanelle always indicates 
some abnormality. A bulging of the anterior fon- 
tanelle usually indicates an increase of fluid in the 
ventricles, while a depression calls attention to a 
lack of body fluid. A delayed closing of the fon- 
tanelle, in like manner, gives evidence of some disor- 
der, usually rachitis. 

The spine. — The spine, which we have noted as 




A. Anterior Fontanelle. 

B. Posterior Fontanelle. 

C. Lateral Fontanelle. 

Skull of an Infant at 
Birth. 




Skull of an Adult. 

FIGURE 14. 

Comparison of Skull of an Infant at Birth 

with the Skull of an Adult. 



35 



36 



ELEMENTS OF PEDIATRICS 



being largely cartilaginous at birth and very flexible, 
loses its flexibility and gradually becomes ossified. 
Moreover, with the growth of the child and its as- 
sumption of the erect posture, certain curves are 
developed in the spine which are entirely absent at 
birth. Thus, at birth there is a curve with the con- 
vexity backward from the neck to the sacrum ; while 
with the assumption of the sitting posture two curves 



Infant 
At Birth 



Infant 
Sitting 



InPant 
Standing 




FIGURE 15. 

Spinal Cueves. 

develop, a cervical curve with the convexity forward, 
and a dorsal and lumbar curve with the convexity 
backward. On standing, a third curve develops in 
the lumbar region, and we have then a curve with 
the convexity forward in the cervical region, a curve 
with the convexity backward in the dorsal, and a 
curve with the convexity forward in the lumbar 



DEVELOPMENT 37 

region. The curve with the convexity backward in 
the sacral region persists during all these periods. 
(Figure 15.) 

Growth in length of the spine. — As the spine grows 
in length, the lumbar portion shows the greatest in- 
crease. Thus while at three months the cervical por- 
tion is 24 per cent., the dorsal 48 per cent., and the 
lumbar 28 per cent, of the total length, at sixteen 
years the cervical is but 21 per cent., the dorsal 47 
per cent, and the lumbar 32 per cent. 

Growth of brain. — Although the brain is large pro- 
portionately to the other parts of the body at birth, 
it increases rapidly in weight during the first three 
years of life. (Figure 16.) During the first year it 
doubles its weight, increasing from thirteen ounces 
to one pound, ten ounces ; at two years it reaches one 
pound, fourteen ounces in weight ; and at three years, 
two pounds, two ounces. From the third to the 
tenth year it increases only about an ounce a year, 
weighing about two pounds, nine ounces, at the tenth 
year. 

Growth of post nares. — The opening from the nares 
into the pharynx, which is very small, almost doubles 
in size during the first year, increasing in measure- 
ment from % inch high by % inch wide to % inch 
high by % inch wide, reaching at this age about half 
the size it is in adults. At seven months it reaches 
the adult type in shape. 

Importance of nasopharynx. — The nasopharynx is 
a most important region in children, since it is 
the seat of the adenoid or third tonsil, which is fre- 



Weight 

3 LBS. 
150Z. 
14 
13 
12 
11 
10 
9 
8 
7 
6 
S 
4 
3 
2 
1 
2LB3 
150Z. 
14 
13 
12 
11 
10 

e 
e 

6 
5 

4 

3 

2 

1 
ILB 
15 OZ. 
14 

13 A 
12 
11 
10 

9 

8 

4 B 
3 

» D 
E 
F 


-Tea.r.3 

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FIGURE 16. 

A. Brain. B. Liver. C. Lungs. D. Heart. E. Kidney. F. Spleen. 

The Increase in Weight of Certain Organs During Infancy and 

Childhood. 



DEVELOPMENT 39 

quently hypertrophied during the first two years of 
life, giving rise to the so-called adenoid growth which 
often becomes a large mass that completely fills the 
nasopharynx. The pharyngeal tonsils do not usually 
cause trouble as early in life as this adenoid or third 
tonsil. 

Dentition. — There are two complete sets of teeth, 
the first or milk teeth numbering twenty, ten upper 
and ten lower, which are, after the sixth year, grad- 
ually replaced by the permanent teeth. 

Development of first dentition. — The development 
of the first set of teeth begins at about the seventh 
week of intra-uterine life, so that at birth these 
twenty embryo teeth are enclosed in the alveolar 
processes, covered by the mucous membrane of the 
gums. This fact is worth remembering, inasmuch 
as solicitation is frequently aroused by very late 
dentition, for in such cases the teeth are in place just 
as in children with early dentition, the difference 
being that in one case these teeth have pierced the 
gums, in the other they have not. 

Age at which first tooth appears. — It may be 
roughly stated that the first tooth usually appears at 
about the eighth month. Exceptions to this rule are 
not infrequent. Children have been born with teeth 
already erupted and not infrequently the lower mid- 
dle incisors appear at the fourth or fifth month. 
One may summarise teething in general in the fol- 
lowing manner, which renders it easy to remem- 
ber. 



40 



ELEMENTS OF PEDIATRICS 



No teeth at six months. 
Six teeth at twelve months. 
Twelve teeth at eighteen months. 
Second teeth beginning at six years. 

The first teeth to appear then may be looked for at 
about the eighth month, and are the two middle lower 
incisors (Figure 17). Both middle lower incisors 



Incisor 



Canine 



Molar 



11 Mos. 




27 Mos. 



<J \y- 



27 Mos. 




Molar 

Canine 

Incisor 8 Mos. 

FIGURE 17. 

First Dentition. 

Indicating the Age of Eruption of the 
Teeth. 



usually appear before any other teeth, then the two 
middle upper incisors, and after these the two lateral 
upper incisors. This set of six teeth should be com- 
pleted before the end of the first year. 



DEVELOPMENT 41 

During the first half of the second year the lateral 
lower incisor and the four anterior molar teeth 
should make their appearance, while during the sec- 
ond half of the second year the four canine teeth, 
popularly known as the eye and stomach teeth, ap- 
pear, followed during the next six months by the four 
posterior molar teeth, which complete the first set. 
The first dentition is thus completed normally in 
about two and one-half years. 

It will be noted that beginning with the middle 
teeth, the teeth erupt in steady progression from the 
front toward the back teeth, with this exception, that 
the canine teeth usually appear after the first four 
molars. 

Second dentition. — At the sixth year, four perman- 
ent molars appear, external to the first set of teeth 
and without replacing any of these, during the 
seventh year the middle incisors drop out and are 
replaced by the four middle incisors of the per- 
manent set, which are much larger than the displaced 
teeth: (Figure 18.) 

During the eighth year the four lateral incisors re- 
place those of the first set; 
During the ninth year the four internal bicuspids 

replace the four first molars ; 
During the tenth year the four external bicuspids 

replace the four second molars ; 
In the eleventh year the canine teeth are replaced 
by those of the second set, while in the twelfth 
year the four second molars appear external to the 



42 



ELEMENTS OF PEDIATRICS 



teeth already in place; and much later, between 
the seventeenth and twenty-fifth year, the four third 
molars or so-called wisdom teeth penetrate the gums. 
As in the first set these teeth in general erupt pro- 



Incisors 
Canine 



Bicuspid 



Molars 



7 Years 

8 Years 
11 Years 
9 Years 
10 Years 
6 Years 



Molars 



Bicuspid 




18 Years 



12 Years 



9 Years 
11 Years 
Years 
7 Years 

FIGURE 18. 

Second Dentition. 

Indicating the Age of Eruption of the Teeth. 

gressively from the middle teeth to the back teeth 
with two exceptions. The first teeth of the second 
set are four molars and the canine teeth appear 
after all the bicuspids. 

Age at which second teeth appear. — The second or 
permanent set of teeth then, beginning to appear at 
the sixth year « and being completed between the 
seventeenth and twenty-fifth year, consists of thirty- 



DEVELOPMENT 43 

two teeth — eight incisors, four canines, eight bicus- 
pids and twelve molars. The time for the eruption 
of each set is roughly as stated. Syphilitic children 
are said to be apt to have early dentition, while in 
that very common disorder — rachitis — dentition is 
often much delayed, and in a very rare disorder, cre- 
tinism, dentition is still more markedly delayed. 

Hutchinson's teeth. — In children with hereditary 
syphilis a characteristic peculiarity of the incisor 
teeth of the permanent set is often noticed. These 
teeth are called Hutchinson's teeth and have a ten- 
dency to taper at the end, the biting surface being 
notched or concave. It should be remembered that 
this appearance in the teeth of the first set has no 
such significance. 

Disturbances of dentition. — The teeth of most chil- 
dren pierce the gums with little or no disturbance. 
Text books do not emphasise the disturbances caused 
by dentition probably because all consultants see 
cases of serious disease attributed to dentition by 
careless observers. While no general symptoms 
should be attributed to dentition until all other pos- 
sible causes have been excluded, the student should 
understand that severe symptoms may be caused by 
teething ; these are sore gums, pharyngitis, fever and 
anorexia. The infant puts its fingers to its mouth, 
but complains if pressure is made on the gums. The 
pharyngitis may give rise to a cough. The temper- 
ature may reach 104 or 105, although commonly much 
lower. With these symptoms the child often loses its 
appetite. There is usually only a slight loss of appe- 



44 ELEMENTS OF PEDIATRICS 

tite but occasionally a child will refuse absolutely all 
food, so that feeding with a stomach tube must be 
resorted to. 

On examining the child the gums are found to be 
red and swollen over the teeth that are erupting. If 
the edge of the tooth can be seen through the gum it 
may readily be rubbed through. For this purpose 
the handle of a teaspoon that has been sterilised in 
alcohol or boiling water is convenient. With this, 
firm pressure with a stroking motion is made over 
the edge of the tooth, so that the gum is really pierced 
by the tooth. When the tooth has thinned the gum 
well, it readily comes through and this gives much 
relief to the child and a subsidence of symptoms may 
result. In any case where such symptoms are pres- 
ent with teething, even if the edge of the tooth cannot 
be seen, some relief may be obtained by such rubbing 
of the gums. 

The thymus gland. — The thymus gland, which is 
situated beneath the upper part of the sternum, 
weighs, as found at autopsy, approximately 6 grams. 
There is no evidence that a normal thymus gland 
shows any growth or atrophy in infancy or early 
childhood. 

Increase in weight of heart. — The heart weighs 
about 6 drachms at birth and increases in size quite 
slowly during the first seven years. It weighs about 
7/4 drachms at the end of the first year (Figure 16) ; 
at the seventh year 2% ounces, and at the fourteenth 
year 5% ounces. From the seventh to the fourteenth 
year its increase in weight is more rapid. 



DEVELOPMENT 45 

Position of heart. — The position of the heart in the 
new born is, as we have stated, more nearly hori- 
zontal than in the adnlt, the apex being on abont the 
level of the nipple and external to it. With the 
growth of the body, this position becomes more per- 
pendicular, the apex moving inward, finally reaching 
its normal adnlt position considerably below the nip- 
ple and midway between the nipple and median line. 

Growth of lungs. — The lungs grow rapidly in 
weight, increasing nearly three times during the first 
year (Figure 16) — from one ounce six drachms at 
birth to four ounces two drachms at one year. A 
rapid gain in weight continues until the fourth year, 
when they weigh about eight ounces, two drachms, 
then gaining more slowly in weight, so that at the 
thirteenth year they weigh more than a pound. 

Changes in structure of lungs. — The structure of 
the lungs is constantly changing from the type of 
infancy, as already described, to the adult type. Be- 
tween the fourth and fifth year the proportional adult 
development between alveoli and bronchi is obtained. 

Increase in size of liver. — The liver, although pro- 
portionately large at birth, weighing one-fourth 
of a pound, increases rapidly in size throughout child- 
hood (Figure 16) ; it more than doubles in weight 
during the first year and continues to increase 
rapidly in size throughout childhood and youth. 

Position of liver. — Being larger proportionately 
than in the adult, it extends below the free border of 
the ribs, usually about one-half of an inch. 

Fatty liver. — It is normally much more fatty in 



46 ELEMENTS OF PEDIATEICS 

children than in adults, and with certain diseases 
readily becomes much enlarged and extremely fatty. 

The spleen. — The spleen at birth weighs only three 
drachms, at one year it has more than doubled in 
weight, being six and one-half drachms; it again 
doubles its weight by the third year, and after that its 
increase is progressive with the increase in the de- 
velopment of the body. (Figure 16.) 

The kidneys. — The two kidneys together weigh 
only three drachms at birth. They increase more 
than five times in weight during the first year, at the 
end of that time weighing two ounces. The weight is 
again doubled by the seventh year, being then four 
ounces, six drachms. (Figure 16.) 

Bovaird and Nicoll in a study of the weight of the 
organs in infancy, state that the weight of the liver 
will average seven times that of the heart, and the 
weight of the spleen one-tenth that of the liver and 
the kidneys one-ninth that of the liver. 

Digestion — sucking. — Sucking is the first process 
connected with digestion. In this act the nipple is 
firmly held between the upper lip and roof of the 
mouth above and the lower lip and tongue below. 
The nasopharynx is closed off by the soft palate, 
and by a backward and downward movement of the 
lower jaw the suction force is applied which causes 
the flow of milk. This act of sucking allows the milk 
to enter the mouth gradually, and stimulates the 
gastric juice. It is noteworthy that cleft palate or 
harelip, or complete nasal obstruction, interferes 
with this act. 



DEVELOPMENT 47 

The saliva. — Saliva, the first digestive fluid with 
which food comes in contact, is practically absent 
at birth; at the third or fonrth month it is pres- 
ent and possesses active starch digesting properties, 
and with teething a further increase in its secretion 
is observed. 

The stomach — position. — The stomach is, in the foe- 
tus, nearly vertical; in the newly-born it lies 
obliquely, while in the adult it occupies nearly a 
transverse position. Its shape also gradually 
changes, for while cylindrical in the foetus, at birth it 
shows but slight bulging, but the fundus is developed 
soon after birth. 

Stomach capacity. — The capacity of the average 
stomach at different ages is a matter that it is most 
important to determine as definitely as possible, in 
order to arrive at a conclusion as to the amount of 
food that should be given to infants at different ages. 
Several methods may be used in the endeavour to 
arrive at the normal capacity of the stomach. The 
stomach of infants may be removed at autopsy, filled 
with fluid, and this fluid measured. By this method 
Dr. Holt has measured the capacity of stomachs of 
ninety-one infants under fourteen months of age, 
and, as the results of these observations, has prepared 
the figures appearing in Figure 19. On the other 
hand, Dr. Rotch, using the same method adopted by 
Dr. Holt, as well as the other method of weighing 
nursing infants just before and just after nursing 
and thus determining by the difference in weight the 
amount of milk swallowed during nursing, has ar- 



48 ELEMENTS OF PEDIATKICS 

rived at the figures shown in Figure 19, as repre- 
senting the gastric capacity at different ages. These 

FIGURE 19. 
STOMACH CAPACITY 

Rotcli Holt Average 

Birth 5 to 1 ounce 1.2 ounces .5 ounce 

1 month 2.5 ounces 2. " 2. " . 

2 months 3.2 " 3.4 " 3. " 

3 months 3.3 " 4.5 " 4. " 

4 months 3.5 " 5. " 5. ". 

5 to 6 months 3.6 " 5.75 " 6. " 

7 to 8 months 6.88 " 7. " 

lOto 11 months 8.14 " 8. " 

12 to 14 months .... . 8.90 " 9. " 

figures, while not corresponding entirely, are fairly 
similar in many respects. 

Errors are easily made in measuring the capacity 
of the stomach by filling the stomach removed at 
autopsy, the capacity so found depending upon the 
amount of pressure used. Thus Pfaundler found 
that while measuring in different experiments the 
capacity of the stomach, first with no pressure and 
then with varying amounts of pressure up to that of 
thirty centimeters, or about one ounce of water, he 
obtained in some cases wonderfully different results, 
the gastric capacity increasing sometimes by one- 
half, in other cases to five or ten times the original 
capacity, and in a few cases to nearly twenty times 
the original capacity. These experiments, while 
showing clearly the elasticity of the gastric wall — a 
condition known to exist in both the stomach and 



DEVELOPMENT 49 

intestine— are not valuable as an indication of the 
amount of food required. As a deduction from these 
different experiments and in order to put this matter 
of gastric capacity in a form easy to remember and 
at the same time sufficiently accurate, one may say 
that infants at birth usually have a gastric capacity 
of one-half to one ounce; that at one month the gas- 
tric capacity is two or three ounces, and that for each 
succeeding month up to six months the gastric ca- 
pacity is equal in ounces to the number of the month 
of age plus one; that from the sixth to the eighth 
month it is equal in ounces to the number of the 
month, and for the remainder of the year it is less 
than the number of the month. Thus at one month, 
two or three ounces ; two months, three ounces ; three 
months, four ounces, etc., up to the sixth month, when 
it is six ounces; the eighth month, eight ounces; at 
twelve months, nine ounces, and at eighteen months, 
twelve ounces. 

For children up to four or five years old, I believe 
it is a good rule to consider the gastric capacity as 
never more than a pint. 

The intestines. — While on account of the elastic 
nature of the tissue it is difficult to state accurately 
the length of the intestine, it may be said that the 
intestine of the infant is longer in proportion to the 
length of the body than in the adult. The small in- 
testine at birth is about nine feet long and the large 
intestine with the sigmoid flexure adds twenty-seven 
inches more, making in all eleven feet three inches 
from the stomach to the anus. The small intestine 



50 ELEMENTS OF PEDIATRICS 

grows about two feet in length during the first month 
and two feet more during the second month, after 
which time the growth seems quite irregular, the 
length of the small intestine in children a year old 
varying often between fourteen and eighteen feet. 
The large intestine at one year is about two and one- 
half feet long. 

The caecum. — The caecum and vermiform appendix 
are much more movable than in the adult and are 
often situated higher in the abdominal cavity. The 
caecum and adjacent lymph nodes are a frequent seat 
of inflammation. 

The pancreas. — The pancreatic secretion during 
the first six months has but feeble power to convert 
starches into sugar, but after the first year this prop- 
erty of the pancreatic juice is fully developed ; it also 
emulsifies fats and converts protein into peptones. 

The liver. — The liver of the newly-born supplies 
little bile, although some bile is said to be secreted as 
early as the third month of foetal life. This bile aids 
the digestion of fats and has a slight action in con- 
verting starch into sugar. The intestinal secretion 
is supposed to have a diastatic or starch-converting 
action. 

Absorption from the intestine. — The absorption 
of food from the alimentary tract begins in the 
stomach, where water, salt, sugar and peptones may 
be taken up by the blood. The peptones split up into 
amino acids before absorption. The small intestine 
may absorb these same bodies and, in addition, fats. 
From the large intestine there is no absorption of fat 



DEVELOPMENT 51 

and but moderate absorption of sugar, salt and pep- 
tones. The milk sugar alone in the food of a 
healthy nursing infant may be completely absorbed ; 
a certain percentage of the protein and of the fats, 
about 2 to 5 per cent., are passed in the feces. Occa- 
sionally large amounts of fats may be almost entirely 
absorbed. 

Intestinal bacteria. — Although bacteria abound in 
the intestinal tract of adults, they are always absent 
from this passage in the newly born and are only 
present after being introduced through the mouth or 
rectum. A great deal of work has been done on the 
bacterial invasion of the intestinal tract and it is 
found that ordinarily this invasion takes place during 
the first twenty-four hours of life, sometimes as early 
as the fourth hour and sometimes not until the seven- 
teenth hour. 

This contamination of the alimentary tract may 
take place by means of anything that passes into the 
mouth or rectum which is not sterile ; most often from 
some food, from contaminated fingers, from bacteria 
in the dust of the air, or from bacteria in the clothing. 

Experiments have also been undertaken in order 
to ascertain whether a certain number of bacteria in 
the intestinal tract may not be useful, if not neces- 
sary, auxiliaries to the process of digestion. 

Nuttall and Thierfelder, from a series of experi- 
ments on guinea-pigs, in which the young were re- 
moved under aseptic precautions by Caesarean sec- 
tion and then kept in a sterile room supplied with 
sterile air and on sterile food, thus keeping the intes- 



52 ELEMENTS OF PEDIATRICS 

tinal tract free from bacteria for thirteen days, con- 
clude that at least for guinea-pigs the presence of 
bacteria in the intestine is not necessary. 

On the other hand, Schottilius, in similar experi- 
ments on chickens, which were kept up for seventeen 
days, found that those in which the intestinal tract 
was thus protected, did very badly and were at the 
point of death when the experiments were concluded; 
while the control animals under ordinary conditions 
did well. 

A safe conclusion from the experiments that have 
been performed, and experience with children, would 
seem to be that a moderate contamination of the 
intestine with nonpathogenic bacteria soon after 
birth does no harm, while contamination of the intes- 
tine with a great many bacteria, or with pathogenic 
bacteria, should be carefully avoided. The absolute 
exclusion of bacteria from the intestines of a child is 
practically impossible. 

Two varieties of bacteria are found constantly 
present in the intestine of children, associated with 
other varieties. These two are the bacillus lactis 
ssrogenes, which is found most abundantly in the 
small intestine, this bacterium appearing to require 
the presence of milk sugar; and the bacillus coli com- 
munis, which we find in greater abundance in the 
colon. The bacillus acidophilus and the bacillus 
perfringans are commonly found in the stools. The 
bacillus bifidus, a Gram positive bacillus, is abundant 
in the stools of nursing infants. These are only a 
few of the more abundant bacteria. 



DEVELOPMENT 53 

Temperature. — The temperature of children is 
about as it is in adults. A temperature of 99° Fah- 
renheit by rectum should be considered normal. 
Some babies and young children may have continually 
a rectal temperature of 98 to 100° with no evidence of 
illness. Temperatures above 100° are an indica- 
tion for a thorough physical examination. Sub- 
normal temperatures are often found in feeble chil- 
dren. 

The pulse rate. — The pulse rate varies from birth 
to adult life, a gradual slowing of the pulse taking 
place. In foetal life the pulse runs between 120 and 
140, and it has been said that a pulse of 120 to 130 
was an indication of a boy baby, while one between 
130 and 140 indicated a girl. This sign of sex, I 
believe, is absolutely worthless. In the early weeks 
of life, this same variation between 120 and 140 is 
observed, and until the end of the first year the pulse 
is usually over 100 ; until the eighth year usually over 
90; and until the twelfth or fourteenth year usually 
over 75. The pulse is much more variable in fre- 
quency than in the adult, being easily accelerated by 
slight shock or excitement. The pulse rate may be 
tabulated as follows : 

At birth 120-140 

At one year 100 

At eight years 90 

At twelve years 75 

Respiration. — The respiration, as we have noted, at 
birth is rather rapid and particularly irregular in 



54 ELEMENTS OF PEDIATRICS 

rhythm. Respirations vary in rapidity with age 
about as follows : 



After birth 35 respirations per minute 

At one year 27 

At two years 25 

At six years 22 

At twelve years 20 






Thus it is only at the twelfth year that the respira- 
tions reach the adult rate. These respirations are 
usually slower during sleep than when the child is 
awake. 

The type of respirations is quite different from the 
adult type, being largely diaphragmatic up to the 
seventh year. One important fact to remember is 
that in infants the lungs do not always expand 
equally, so that at certain times, particularly in 
poorly nourished children, respiration may be car- 
ried on largely by one lung; therefore, on examina- 
tion marked dullness on percussion and absence 
of breathing may be noted over a portion or the 
whole of one lung. These signs disappear entirely 
as soon as the infant is made to cry or to exert itself 
in some way. 

The urine. — The urine, we have noted, is in the 
newly-born of high specific gravity, scanty in amount, 
and apt to contain uric acid crystals. The specific 
gravity falls in two or three days as low as 1003, 
while by the fifteenth day it is 1006. 

Throughout infancy the amount of urine passed is 
relatively greater than in adult life, probably due in 



DEVELOPMENT 



55 



part to the fact that only liquid food is given. The 
amount of urine passed is about as indicated in 
Figure 20. 

FIGURE 20. 

DAILY SECRETION OF URINE AT VARIOUS AGES 



2 ounces or an average of 1 ounce 



a a a 


' 2 oun 


a a n 


' 5 " 


a a a 


< 8 " 


an a 


1 10 " 


an a 


' 15 " 


an a 


' 20 " 


ex a a 


1 30 " 


tilt a 


'38 " 




40 " 



1st day 

2nd day 1-3 

1 week 5-8 

1 month 5-13 

6 months 8-16 

1 year 8-20 

3 years 15-25 

6 " 20-40 

11 " 31-47 

12 " 



The maximum amount for the first twenty-four 
hours is but two ounces ; for the second, three, while 
during the first week but three to eight ounces a day 
are passed ; at six months, a half pint in the twen- 
ty-four hours, while from the eighth to the four- 
teenth year a quart to a quart and a half may be 
passed. 

Figures that can be easily memorised and referred 
to in clinical work are as follows : 

Urinary secretion at birth, one ounce a day. 
At six days, five ounces a day. 
At six months, ten ounces a day. 
At six years, thirty ounces a day. 

In very young children the urine is passed fre- 
quently, often every half hour during the day, al- 



56 ELEMENTS OF PEDIATKICS 

though during sleep it may be retained from two 
to six hours. 

Specific gravity of urine. — The specific gravity of 
the urine remains low throughout early childhood, 
and during the first two years when the diet is largely 
fluid, is often found between 1006 and 1012. In 
older children it is more concentrated, reaching 1015, 
1020, or even 1030, if care is not taken to give them 
plenty of water. 

Frequency of micturition. — Accurate observations 
on the frequency of micturition in children have been 
made by Engle. He placed the child over a chamber 
with an electric current so arranged that a bell was 
rung whenever urine was passed. He found that the 
average infant, taking twenty-seven ounces of food, 
urinates from twenty-five to thirty times during 
twenty-four hours, and when the food is increased to 
fifty-four ounces the child urinates from fifty to sixty 
times in twenty-four hours, or every twenty -five or 
thirty minutes. He also found that very young 
children void urine at fairly regular intervals 
whether awake or asleep, but that after six months 
they urinate only when awake. 



CHAPTER IV 

THE CARE OF THE HEALTHY INFANT 

Infant mortality. — The necessity for an under- 
standing of the proper care of infants is, perhaps, 
best shown by considering the enormous mortality 
in infancy as compared with adults, a mortality that 
would be greatly reduced could all infants receive 
proper care. 

About one-fourth of all deaths occur in children 
under one year of age, while about one-half of all 
deaths occur in children under fifteen years of age. 
The total mortality, including adults, in well con- 
ducted communities varies between thirteen and 
twenty per thousand each year, at certain times and 
places being as low as ten or as high as thirty. The 
mortality of infants under one year is in general 
about ten times this amount. 

Infant mortality in various countries. — In Rou- 
mania (Figure 21), 50 per cent, of all babies are said 
to die in the first year, and in Russia 26 per cent. 
The mortality is less in other countries as shown 
by the table. In the United States registration area 
in 1911 it was 13 per cent.; in New York State, 15 
per cent. ; in New York City in 1916 it was only 
9.3 per cent., comparing very favourably with that 

57 



58 ELEMENTS OF PEDIATRICS 

of many other places, while in Sweden the mortality 
is said to be only 7.5 per cent. 

FIGURE 21. 

DEATH RATE OF INFANTS UNDER ONE YEAR 
IN VARIOUS COUNTRIES 

Roumania 50 per cent. 

Russia 26 per cent. 

Austria-Hungary 22 per cent. 

Germany 19 per cent. 

Italy 17 per cent. 

United States 13 per cent. 

England 12 per cent. 

France 10 per cent. 

Sweden 7% P er cen t. 

Reduction of infant mortality. — In most countries 
the infant mortality has been rapidly reduced while 
in some countries, such as England, where it has 
never been very high, but little diminution has been 
obtained. 

The mortality in the first month of life is as large 
as that during the second and third years together. 

Causes of infant mortality. — This infant mortality 
while dependent somewhat on the heat in summer 
and on the congestion of population, particularly in 
factory towns where many of the inhabitants are 
poor, may be reduced by regulation of sanitary con- 
ditions, protection of pregnant mothers, proper 
supervision of child birth, and care of infants. 

Causes of infant mortality. — Hot weather in cities. 
— The infant mortality during July, August and 
September in the cities is always high. The exces- 



CAEE OF THE HEALTHY INFANT 59 

sive heat debilitates the baby rendering it less able 
to digest its food, and at the same time favours bac- 
terial growth in food that is not properly cared for, 
and on this account diarrhoea is much more common 
in summer in artificially fed infants. 

Variation in infant mortality by months in New 
York. — The accompanying chart (Figure 22), shows 



Months 


Jan. 


Feb. 


Mar. 


Apr. 


May 


June 


July 


Aug. 


Sept. 


Oct. 


Nov. 


Deo. 


Ho. of deaths 
2200 

2000 

1800 

1600 

1400 

1200 

1000 

800 

600 














A 
























j 


i 




















i 

/ 
i 




\ 
\ 
\ 




















i 


A 


\ 










B v 




/ 
/ 

/ 


— -\ 

\ 


s 




r 




\ 

\ 








\ 
> 


* / 






V 


1 




\ 




















J 




\ 


V 


\ 

\ 

N 










r 


^\ 


\/ 


/ 






\ 




w 
\*>" 


-'-& 


*\ 


s/ 


r 




V 










\ 


■v 


























—A 



FIGURE 22. 
A. Infants under one year. B. Children under five years 
Deaths of Infants and Children by Months in New York. 



the variations in infant mortality by months in New 
York, and is fairly typical although yearly varia- 
tions occur. It is interesting to note that while the 
mortality of infants under one year in winter is 



60 ELEMENTS OF PEDIATBICS 

about one-half the mortality of all children under 
five years of age, during the hot months it amounts 
to about three-fourths that mortality. 

Infant mortality in summer. — The mortality, 
moreover, is apt to be higher in July than in August, 
although often the weather is quite as hot in August. 
This is thought to be due to the fact that in July very 
susceptible babies succumb and that those who are 
able to survive the heat of July have a better chance 
to withstand the heat of August. 

Humidity. — Humidity, as well as heat, is a con- 
siderable factor in the discomfort of babies in hot 
weather and may to some extent be an influence in 
this infant mortality. The heat is, however, by far 
the more important because it spoils the child's food 
as well as reducing its resistance to infection. 
Breast fed babies do not have a high mortality in 
summer. 

Poverty. — It is among the infants in tenements, 
those of the very poor, where the rules for care, 
which are here pointed out, are least heeded that the 
mortality is the highest. Under these conditions, 
many of the requirements mentioned are not easily 
carried out on account of the onerous duties of the 
ordinary tenement house mother with her household 
work and the care of a large family. 

Illegitimacy. — Illegitimate children, naturally, 
have less care, and show much higher mortality than 
legitimate children. 

Artificial food. — The mortality is less where most 
infants are nursed at the breast, as in Scandinavia, 



CAEE OF THE HEALTHY INFANT 61 

and highest where artificial foods are largely 
used. 

It is thus evident from the study of the four prin- 
cipal causes of the high infant mortality, that un- 
hygienic surroundings and bad feeding are the main 
factors. 

Measures for reducing infant mortality. — The high 
infant mortality is being rapidly reduced in intelli- 
gent communities by milk depots and agencies that 
instruct the mothers of the poor to nurse their babies 
as far as possible and if artificial food is needed 
to give sterile food which will properly nourish the 
babies, as well as instruction in other precautions 
necessary for good health. 

Mortality of babies in private practice. — In contrast 
to the foregoing figures of infant mortality, the 
mortality of babies in private practice, where ample 
instruction is received and every care is taken, gives 
a good example of what may be accomplished and 
what will soon be accomplished among the intelli- 
gent people of the poorer classes. Of these children 
having every care not more than one in 100 or 150 
die in the first year, although they are largely arti- 
ficially fed and if nursed it is often only partially or 
for a few months, and these figures include the babies 
with congenital defects. The writer has published 
recently a series of 120 consecutive cases with no 
death. It is very rare, under good conditions, to 
lose a child during the first year, for these children 
are well isolated and are thus protected from con- 
tagious diseases, while their feeding, exercise and 



62 ELEMENTS OF PEDIATRICS 

exposure to fresh air can be absolutely controlled. 
In order to obtain these good results that have been 
mentioned it is necessary to take every precaution 
and there are no details so small that they should not 
be looked after by the physician. 

One of the most successful consultants in pedia- 
trics in a neighbouring city on taking charge of an 
artificially fed baby was in the habit of modifying 
the milk himself one day, so as to give the mother or 
nurse a practical lesson in the method used, in order 
that there might be no mistakes made in carrying out 
his directions. It is only by care in the smallest 
details that the greatest success in pediatrics is 
obtained. 



CHAPTEB V 

THE CAKE OF THE INFANT DUKING THE FIRST DAY 

Respiration. — At birth, our first care, with respect 
to the infant, should be to establish respiration. 
Infants at birth are often cyanosed, and their breath- 
ing is shallow and insufficient. At birth, the lung is 
a solid organ, and inflation must gradually take 
place. In autopsies on babies two or three days 
old, sometimes only one-half of the lung tissue is in- 
flated. At birth, then, the baby should be held by its 
feet to let the mucus run out of its mouth. Should 
the baby not cry vigorously of itself (the cry assists 
in the establishment of respiration) it should be 
slapped on the buttocks and if respiration is still 
insufficient, the baby should be dipped alternately in 
hot and cold water. Should this not be sufficient, 
artificial respiration may be used. Again, inflation 
of the lungs by means of a lung motor may be re- 
sorted to, while traction on the tongue applied eight 
or ten times a minute, is also of use in stimulating 
respiration. Babies that fail to react and remain 
persistently cyanotic are usually suffering from 
some congenital defect. 

Congenital heart defect. — The most common defect 
is in the heart and is usually associated with a loud, 
harsh systolic murmur and a thrill. In these cases, 
there is generally a stenosis of the pulmonary orifice 

63 



64 ELEMENTS OF PEDIATRICS 

as well as a defective intraventricular partition 
allowing a rush of blood from one ventricle to the 
other in systole. In other cases without murmur 
there may be a patent foramen ovale, while in other 
cases of cyanosis the defect is not in the heart at all, 
but in the formation of the diaphragm — a hernia of 
the diaphragm, the intestine occupying a part usually 
of the left half of the thorax crowding the heart over 
to the right side. 

Cutting the cord. — When respiration has been 
well established, the cord may be tied twice with 
sterile ligatures and cut between the ligatures with 
sterile scissors to prevent unnecessary loss of blood. 
It should be handled with sterile gloves. Especial 
care should be taken that a knot is tied that cannot 
slip. At the Sloane Maternity Hospital in New York 
four knots are tied. First one around the cord, then 
one over the end encircling one artery, then one over 
the second artery, and finally around the whole cord 
a second time. 

The navel. — The care of the navel is most im- 
portant, for here we have a surgical wound in the 
child at its least resistant age. We have constantly 
more reason to believe that many illnesses of the 
new born are due to navel infections. The navel 
should be kept dry and have a dressing of sterile 
gauze, and especial care should be taken that it is not 
moistened or soiled by wet diapers or fecal material. 

The eyes. — The eyes should be carefully cleansed 
with saturated boracic acid solution, and two or 
three drops of 1 per cent, nitrate of silver solution 



CAEE OF INFANT DURING FIRST DAY 65 

or 20 per cent, argyrol solution should be instilled in 
each eye. This nitrate of silver, although irritating, 
does not cause inflammation and does prevent the 
subsequent appearance of ophthalmia. 

Ophthalmia. — Ophthalmia is usually due to a gono- 
coccus infection of the eyes during birth, and the pos- 
sibility of such an infection can rarely be absolutely 
excluded. Ophthalmia is the cause of a great deal 
of blindness among children, especially those deliv- 
ered by ignorant midwives, and should rarely occur 
in the practice of a properly instructed person. 
The use of the nitrate of silver or argyrol is a wise 
precaution, and should be used as a routine practice. 

Examination. — A careful examination should now 
be made of the child. The shape of the head is 
often distorted at birth, and the bones crowded 
together. The size of the f ontanelles may be noted ; 
the mouth should be examined for hare-lip or cleft 
palate, and any evidence of so-called branchiogenic 
clefts about the ears and neck should be recorded. 
Note the size and shape of the abdomen and thorax. 
Examine the genitals, and in the male retract some- 
what the foreskin to determine the presence of a 
sufficient opening for the discharge of urine, and if 
it is insufficient, one may stretch it by retraction. 
Examine the anus for a patent rectum. Note 
whether the palms of the hands and the soles of the 
feet have a normal colour. Listen to the heart ac- 
tion, and respiration, and, finally, weigh the baby 
and take the measurement of its length, circumfer- 
ence of head, thorax, and abdomen. Then make a 



66 ELEMENTS OF PEDIATRICS 

record of what has been noted. All this need take 
but a few moments, and may furnish data of the 
greatest importance in the future care of the child. 

Serious results of the neglect of such an exam- 
ination are constantly appearing. An instance oc- 
curred in the grandchild of a prominent physician, 
the mother having been attended in confinement by 
another physician, where after some time the family 
were disturbed because the child was pale, was short 
of breath and failed to gain in weight. 

An examination was first made when the child was 
two and one-half months old. The child was cyan- 
otic, had respirations of seventy-two a minute and a 
loud, harsh murmur, accompanying a congenital 
heart defect, was heard all over the whole of the 
thorax in front and behind. This child's condition 
was much improved by a modification of its daily 
regime, made advisable by this discovery. 

After the establishment, if necessary, of res- 
piration, the cutting of the cord, and the physical 
examination and recording of the same, the baby 
should be allowed to rest for six hours. It should 
then be washed with warm water, care being taken to 
avoid contaminating the navel. 

Dressing. — The dressing of babies is, in all coun- 
tries absurd. In some countries they are simply 
wound round and round with a binder, which re- 
stricts all movements. With us, too many garments 
are used, and they are difficult to put on and off. 
The ideal clothing for a baby should be simple, warm 
and loose, allowing ample, free movement for res- 



CAEE OF INFANT DURING FIRST DAY 67 

piration, and for the movement of the arms and legs. 

Navel dressing. — To the cut surface of the navel a 
sterile dressing for the cord is applied. A slit is cut 
in a piece of linen six inches square, and through 
this the cord is drawn, and the linen is folded over 
from above down, from below up and from each side 
inward. This dressing should be put on with sterile 
rubber gloves and the dressing should not be touched 
again for five days. 

Binder. — A binder of soft flannel is then applied 
around the abdomen. This is useful during the first 
days in keeping the dressing of the navel in place and 
protecting it from contamination. It is harmless, so 
long as it is not applied too tightly. The respiration 
of the new-born is diaphragmatic, and the diaphragm 
can with difficulty descend if the abdomen is tightly 
bound. The binder should be only so tight as may 
be necessary, in order that it may remain in place, 
and should be discarded when the navel has healed. 
When this is removed, it is often replaced by a gar- 
ment which is really a second undershirt. 

Diaper. — The diaper is next applied. It is an ar- 
ticle that should be superseded by something sim- 
pler, and less bulky, for, in its worst form, as when 
made of canton flannel, it presses the femora out- 
ward, and makes a large mass between the legs of 
the baby, which may have a tendency to bend the 
bones, while at the same time, it prevents free motion 
of the thighs. The best diapers are probably those 
made of stockinet, which is soft, not very bulky and 
quite absorbent. Absorbent gauze, or the so-called 



68 ELEMENTS OF PEDIATEICS 

butter cloth of the dry goods stores, may also be used 
for this purpose, a roll being kept in the nursery and 
each piece being burned as soon as soiled. The use 
of a rubber covering over the diaper is very objec- 
tionable, as it shuts out air and when the diaper is 
wet really poultices the child with its urine. It 
should never be used except for emergencies, when 
dry diapers may not be available. 

Shirt. — A woollen shirt is then put on. It has long 
sleeves, and is buttoned or sewed around the neck 
behind. 

Petticoat. — Over this is worn a petticoat, which is 
made of flannel with long sleeves, low in the neck and 
very long. 

Dress. — While over all is a dress, also very long. 

It is evident that common sense indicates a simpli- 
fication of this costume to a navel dressing, until the 
navel is healed, a binder for a few days to hold the 
navel dressing in place, an improved diaper, and a 
long loose dress. (Figure 23.) This is the ordi- 
nary night costume. The enforcement of such a cos- 
tume during the day is, however, a difficult matter. 

Parents should be warned not to keep their babies 
too warmly clothed. Babies that give much trouble 
by throwing off the bed clothes, do so simply because 
they are kept too warm. This over-covering is the 
cause of considerable danger to babies, since they 
perspire when first put to bed, and then, after their 
skin and night clothes have become damp, free them- 
selves of all covering, and lie with nothing over them 
but their wet night clothes. Wet clothing conducts 



Binder 



i 
.. J 



or 

this 

IU1 




Diaper 
Socks 
Shoes 



Undershirt 





Flannel 
skirt 



Dress 



Clothing all Babies Wear. 





Diaper 



Dress 
Clothing Babies Should Wear. 
FIGURE 23. 



69 



70 ELEMENTS OF PEDIATRICS 

heat and cold. It is only when dry that clothing 
insulates and keeps one warm. Considerable care 
must be taken and each baby individually studied, to 
ascertain just how much clothing will keep the child 
comfortable, without causing perspiration. 

Temperature of room. — As soon as the new-born 
baby is dressed it should be well covered with a blan- 
ket, and kept in only a moderate light, and in a tem- 
perature of about eighty degrees Fahrenheit. It 
must be borne in mind that in intra-uterine life the 
baby has had quiet at a temperature of ninety-nine 
degrees Fahrenheit and a chance for fairly free 
movement of its arms and legs. 

Sleep. — The baby, during this first day, should 
sleep most of the time. Fondling or disturbing a 
new-born baby should be absolutely interdicted. 

Feeding. — Feeding during the first twenty-four 
hours is, with many babies, a matter which gives lit- 
tle trouble. If the baby sleeps almost continually, as 
it should, it may be put to the breast at the end of 
twelve hours, and at intervals of four hours during 
the day thereafter. Before it is pat to the breast, 
the nipple should be carefully and thoroughly 
cleansed with a saturated solution of boracic acid. 

The secretion of the mother's breast during the 
first days is not ordinary breast milk, but a modifica- 
tion of it, called colostrum. 

Breast milk contains fat, 3 to 4 per cent. ; sugar, 6 
to 7 per cent. ; protein, 1 to 2 per cent. ; while colos- 
trum contains, according to an average of many 
analyses about 3 per cent, fat, 4 per cent* sugar and 



CAEE OF INFANT DUKING FIRST DAY 71 

7 per cent, protein. (Figure 24.) The salts in 
colostrum are about three times more abundant than 
in ordinary breast milk, amounting to .7 per cent. 

FIGURE 24. 

ANALYSIS OF HUMAN MILK AND COLOSTRUM 

Low average High average Colostrum 

Fat 3. 4. 3. 

Sugar 6. 7. 4. 

Proteid 1. 2. 7. 

Salts 18 .25 .7 

Water 89.82 86.75 85.3 

100.00 100.00 100.00 

Other analyses have shown as much as 4 per cent. 
fat and only 3 or 4 per cent, protein. While these 
analyses vary in the amounts, they agree as to the 
fact that colostrum contains less fat and sugar and 
more protein than ordinary breast milk. 

On microscopic examination, we find the so-called 
colostrum corpuscles, which are large cells, sup- 
posed to be epithelial cells that have undergone 
fatty degeneration. Colostrum, both human and of 
cows, coagulates on boiling. A purgative action has 
been attributed to this colostrum, which is thought 
to aid in expelling meconium from the intestines. 

The intestine of the infant at birth, as has been 
noted, is sterile, and the infant is very susceptible, so 
that we must guard, as far as possible, from dan- 
gerous infections. 

If the child is restless, and cries continually, and 
gets no comfort from the breast, or cannot be put to 
the breast, it may seem necessary to give it some 



72 ELEMENTS OF PEDIATBICS 

food. If left to the mother and the nurse it is very 
likely to get some tea or sugar water, which may so 
f^. derange the digestive organs that it will 
require considerable time and patience to 
restore it to normal condition. If then, 
the baby needs some food beside what it 
can obtain at the breast, it should be given 
advisedly and with every precaution. 
Sterilised water may be given warm with 
a sterilised medicine dropper, or Breck 
feeding tube (Figure 25) and, if this is 
not taken well, a 4 per cent, solution of 
sugar of milk, sterilised, may be given in 
the same way. The 4 per cent, sugar so- 
lution contains some nourishment, is liked 
by the baby, and does not contain any in- 
gredient that colostrum does not contain. 
It should, however, be given cautiously, 
and not more than a teaspoonful every 
hour or two. The baby requires little 
figure 25. f°°d during the first twenty-four hours, 
Breck and usually nothing but what it can obtain 
Feeding f r0 m the mother's breast. Efforts to 

Tube 

avoid the loss of weight that normally oc- 
curs during the first two or three days before the 
breast milk comes in by giving artificial food have 
not demonstrated any advantage for that method. 

It should be carefully noted whether urine and 
feces are passed, and all diapers containing fecal 
matter should be saved for the inspection of the 
physician. 




CHAPTER VI 

CAKE OF THE INFANT DURING THE SECOND DAY 

The second day, also, of an infant's life presents 
certain problems which should be considered sepa- 
rately before going on to the discussion of the 
hygiene of infancy. 

Urination — Defecation. — It should especially be 
noted whether the infant has passed urine or 
feces. If there is a history of anuria, water should 
be freely administered by the mouth, and, if there 
is still no result, the meatus through the fore- 
skin being patent, a warm saline enema may be 
given, in the rectum, by means of a small sterile 
catheter, in order to stimulate the kidneys to ac- 
tion. It should, however, be remembered that the 
normal excretion of urine during the first twenty- 
four hours of life is only one ounce and all 
unnecessary interference with the child should be 
avoided. An infant size glycerine suppository may 
be used, if necessary, to stimulate the expulsion of 
meconium. 

The eyes. — The eyes should be carefully examined, 
as well as on each succeeding day during the first 
week, to ascertain whether there is any conjunc- 
tivitis, at the very beginning of which active treat- 
ment must always be used. The eyes should be 

73 



74 ELEMENTS OF PEDIATRICS 

washed with a saturated solution of boracic acid suf- 
ficiently frequently to keep them clean, while if there 
is any secretion a smear should be made and stained, 
to determine the infecting germ and a few drops of a 
25 per cent, solution of argyrol or a 1 per cent, solu- 
tion of nitrate of silver should be applied. 

Feeding. — On the second day, it is usually possible 
for the baby to obtain some colostrum, although the 
breasts do not take on full activity before the third 
day. It is necessary at this time to decide whether 
the mother's breasts shall be used for nursing, or 
some other food resorted to. The indications for 
using or discarding the mother's milk we will take 
up later, so it will suffice to say, that, unless there is 
a positive danger to either the child or the mother 
from doing so, the child should be put to the breast 
every four hours during the second day, because 
there is no other food so well adapted to or so easily 
digested by the infant at this time. 



CHAPTER VII 

NURSEKY HYGIENE 

Before considering the daily care of an infant, the 
essential requirements for a satisfactory nursery will 
be briefly reviewed. 

The nursery. — In order to attain good results with 
young children it is desirable that the nursery should 
be a large, well ventilated room, with ample windows 
and light, and a southern exposure. Infants, if born 
in winter, are in the nursery most. of the day, and all 
night. 

The nursery should, if possible, have three thou- 
sand cubic feet of air space. That is, dimensions of 
not less than 15 feet by 20 feet by 10 feet. If one 
has to accept less space, care should be taken that the 
facilities for ventilation are particularly good. 
Good ventilation is, of course, essential, even with 
three thousand cubic feet of air space. The nursery 
should always contain moving, not stagnant air. 

Adjoining the nursery should be a second room 
with space for all the apparatus which pertains to 
a modern nursery outfit. 

The nursery should be free from heavy hangings. 
The walls should be painted, rather than papered, 
and the floor should be hardwood, covered with small 
rugs, rather than a carpet. In short, everything 

75 



76 ELEMENTS OF PEDIATRICS 

should be done to keep it clean, sunny and well ven- 
tilated. 

Ventilation. — Various means for allowing the en- 
trance of air from out of doors, without the produc- 
tion of a distinct draught, have been recommended 
and put into use. Of all means of ventilation the 
open fireplace probably furnishes one of the best, 
thus carrying a constant current of air from the 
room. Such open fireplace must, however, be pro- 
tected by a screen for the safety of the baby. Care 
should be taken that the air that enters the room 
comes from out of doors and not from another part 
of the house. 

Of the devices that may be used for securing out 
of door air without undue wind or dust, one or two 
may be mentioned. One method of ventilation in 
cold weather without draught and without apparatus 
is procured by lowering the upper sash of the win- 
dow one-half inch, and raising the lower sash an 
equal amount, thus allowing a slight inflow of air be- 
tween the two sashes, this air being driven in an up- 
ward direction. Or a piece of wood made in length 
equal to the width of the window and some three 
inches in height, may be placed on the window sill 
beneath the window after it has been raised, so that, 
when the window is placed against this contrivance 
but little air will enter the room from beneath the 
lower sash, while a considerable amount will pass in 
between the upper and lower sashes, thus being pro- 
jected in an upward direction, and preventing any 
draught in the lower part of the room. 



NURSERY HYGIENE 77 

Another simple means of obtaining air without 
draught, and at the same time filtering the dust from 
the out of door air, is the use of a double pair of 
window sashes, the inner pair being the ordinary 
window sashes containing glass, the outer pair being 
covered with cheese cloth. With this arrangement, 
it is possible, even in winter, to have the glass win- 
dows wide open, the air passing through the cheese 
cloth so slowly that, while the air of the room is 
fresh, no draught is perceptible. The objections to 
this latter method are the disfigurement of the house 
as seen from the outside and the exclusion to some 
extent of sunlight. It is, however, by far the most 
satisfactory method of ventilating a room. 

Other patented devices for introduction into win- 
dow frames, some of which also filter the air through 
wire gauze, are available. 

In mentioning these methods of ventilation, the 
elimination of draughts has been noted although 
there is no evidence that draughts ever hurt young 
children ; excepting such draughts as produce intense 
chilling of the body, draughts probably hurt no one 
excepting the people who are afraid of them, and 
some people develop a coryza immediately upon be- 
ing subjected to a draught. Healthy children thrive 
in moving air, and children in a severe condition of 
marasmus may sometimes be saved by placing them 
in an open window in winter, well covered and with a 
hot water bottle at their feet. 

Light. — The nursery should be, for the most part, 
dark from sun-set to sun-rise, and the baby asleep. 



78 ELEMENTS OF PEDIATEICS 

When artificial light is necessary, it should be, where 
possible, a well-shaded electric light. Candles, 
lamps and gas, are objectionable because they con- 
sume oxygen. Very young babies should be kept 
from staring in the light, as they often will do if not 
shaded, but should not during the day be kept in a 
dark corner of the room. The crib should be placed 
near a window. The shades of the nursery should 
be wide open during the day and no heavy hangings 
should be allowed in the nursery windows. 

Arrangement of room. — The nursery should have 
ample floor space, as has been stated, and as little 
furniture as is practicable. This furniture should 
be strong, simple, easy to keep clean, and should be 
kept clean. The crib should be four feet long, with 
sides that cannot easily let down, the giving away of 
the side of the crib being a not infrequent cause of a 
bad fall for children after they grow older and begin 
to stand. The infant should always sleep in a bed 
by itself, in order that it may have good air, and free- 
dom of movement, and to avoid the possibility of 
being over-lain and thus suffocated, the cause of oc- 
casional deaths in infants. In older children, a sep- 
arate bed should be equally insisted upon on moral 
grounds. Canopies hanging over the head of the 
crib are to be looked on with disfavour, as interfering 
with the free circulation of air for the child and also 
as a reservoir for dust. A still more objectionable 
protection to the crib, which is at present quite popu- 
lar, is a quilted hanging enclosing the four sides of 
the crib, placed there ostensibly to prevent the child 



NUESEEY HYGIENE 79 

from hurting itself. It really puts the child at the 
bottom of a padded well and interferes with the free 
circulation of air about the child. 

Two chairs, a table and a bureau for the baby's 
clothes, should about complete the furniture of this 
room, which should be used entirely for the baby, the 
apparel for the nurse being kept in the adjoining 
room. 

The nursery table, for the modification of milk, 
should be in another room and not in a bath 
room, as one often sees it. It should have a glass 
or enamel top, and room for the bottles, a pitcher, a 
glass graduate, a funnel, the lime water, sugar and 
other articles used in preparing the feedings. 

The walls of the nursery should be of a light colour 
and preferably painted. 

Scales. — Certain articles of importance should be 
supplied in every nursery. Good scales for weigh- 
ing the baby should always be provided. Balance 
scales are the best. (Figure 26.) Spring scales are 
very unreliable. A healthy baby is an active, mov- 
ing creature, whose weight it is difficult to get on any 
scale. Spring scales easily move up and down, so 
that it is almost impossible to obtain an accurate 
weight. The scales should have a receptacle for the 
baby that is about eighteen by twelve inches in size 
and is made fast to the scales. The ordinary scoop 
is hazardous. 

Clock. — A good clock should also be provided, as 
everything in the nursery should be regulated, as 
far as possible, by the clock. 



80 



ELEMENTS OF PEDIATRICS 



Thermometer. — A thermometer hung on the wall 
to register the temperature of the room is a good 
precaution against over-heating. For a full term 
baby over a month old the room can be very cool if 
the baby's extremities are kept warm. A bath ther- 
mometer is desirable for testing the temperature of 




FIGURE 26. 
Propee Scales for Weighing Babies. 

the bath and the water in which the bottle is warmed. 
The temperature of the nursery during the first days 
of life should be between seventy and eighty degrees 
Fahrenheit. At the end of the first week a tempera- 
ture of seventy degrees is sufficient and at the end of 
the first month a temperature of sixty to seventy 
degrees may be maintained. There is no objection 



NUKSEBY HYGIENE 81 

after the cliild is more than one month old to having 
the room temperature reduced considerably with 
ample ventilation, for additional bed covers will be 
sufficient to keep the baby comfortably warm. 

Quiet. — The nursery should also be kept as quiet as 
possible, and should be so situated that such quiet 
may be secured. The exceedingly nervous tempera- 
ment of all infants is not usually appreciated, and 
the disastrous effect of noise on babies is well illus- 
trated in all the larger hospitals for children. Thus, 
the nursery should be so situated that it will not only 
be free from disturbing street noises, but should 
also be sufficiently isolated from the other portions 
of the house, so that the child may not be disturbed 
by noises from that source. The nursery should 
never be a sitting-room or a place of social meeting 
for the family. Very young babies may go into a 
condition of acute neurasthenia, becoming nervous 
and sleepless from too much disturbance and too 
much company. A demonstration of the advantage 
of quiet in the care of sick babies was apparently 
made at a hospital where a large ward with forty- 
five beds and many crying babies had a mortality 
of 1.25 per cent, while a small ward of sixteen beds 
with equally sick babies, but with the exclusion of 
crying babies, had a mortality of only 0.6 per cent. 

The nurse. — Our babies probably suffer no greater 
evil than that of incompetent nurses, who, al- 
though often properly instructed, neglect their 
babies when not watched, who prepare the food care- 
lessly, give it at irregular intervals, and in many 



82 ELEMENTS OF PEDIATRICS 

ways interfere with the proper regulation of their 
lives. 

A nurse must be obedient and loyal to both the 
mother of the child and the physician. She should 
be a healthy and amiable woman. It is not sufficient 
that she should be simply a good machine, she must 
take an active and sympathetic interest in the baby. 
Many old experienced nurses are very valuable if 
they have not from their really limited experience 
obtained preconceived ideas which may make them 
unwilling to carry out the orders of the physician, 
feeling that they know better. Their experience, of 
course, although extending over many years, is with 
comparatively few cases, and should not conflict with 
the experience of a physician in active practice. 
Younger women are often more easily controlled, 
and now there are available a large number of 
trained nursery maids who receive a training in an 
institution for less than one year and who demand 
little more in wages than the ordinary servant. 
Where people are well-to-do and especially where 
there are several children in the family there are 
many advantages in having a trained nurse in charge 
of the nursery. She is apt to be a woman of some 
culture and education, if a graduate of one of our 
better training schools, and her supervision should 
be more careful and intelligent than can be given by 
a mother who has had no training and who has many 
other important calls on her time. 

Amusing the baby. — Babies during the first months 
of life should never be amused. The only attention 



NURSERY HYGIENE 83 

they require is to be fed regularly, have their diapers 
changed frequently, kept warm, in a quiet place, with 
good air; in case they are troubled with colic, to 
be turned on their stomachs or put over the shoulder 
and patted on the back. This should be the extent 
of attention given to a healthy child under four or 
five months of age. The ordinary methods of amus- 
ing such babies by dangling bright objects before 
their eyes, by sitting them up straight, and shaking 
them up and down, when they should be kept in a 
horizontal position — all these things tend to induce 
in the baby a condition corresponding to neuras- 
thenia in older persons. It makes them nervous, 
easily startled, and restless sleepers. 

Toys. — After six months, toys for the baby to play 
with may be appreciated, but, during the earlier 
months, too much care cannot be taken to avoid ex- 
citing the baby. 

The physician should exercise supervision over 
the toys that are used to divert the baby. As 
soon as the birth of the baby is announced, play- 
things of all sorts are showered on the poor little 
passive creatures who would much rather be left to 
their sucking and sleeping. Beside disturbing the 
baby, many of these articles are positively dan- 
gerous. 

Certain things to be avoided in the playthings of 
infants are : 

First — Small articles, such as grains, peas, beans, 
pieces of money, which may, when put into the 
mouth, lodge in the air passages. 



84 ELEMENTS OF PEDIATBICS 

Second — Breakable articles, glass, porcelain. 

Third — Articles with sharp corners and points. 

Fourth — Articles made of lead or copper. 

Fifth— Articles which contain the oxide of lead. 

Sixth — Articles painted with dangerous colouring 
material, as well as boxes of paints. 

A toy that is frequently used in the nursery be- 
cause it is always available is a safety pin or a string 
of safety pins. These are often fastened together 
so that they make a noise when shaken and are found 
to answer the purpose of amusing babies. As a re- 
sult, not infrequently they are swallowed by babies 
and in some cases are swallowed open and with the 
point turned back. In one child of a distinguished 
physician six safety pins were swallowed and a long 
period of unexplained fever ensued until they were 
passed. 

In Austria a law has been passed regulating the 
employment of colours for candy and for toys. Con- 
cerning toys, it forbids the use of arsenic, antimony, 
lead, cadmium, copper, cobalt, nickel, mercury, cin- 
nabar, zinc or gutta percha ; and permits other metal- 
lic colours, but these colours must be covered by a 
varnish which resists moisture. As a matter of fact, 
it is well to forbid the use of painted toys for babies, 
since all their toys get into their mouths, and the 
varnish which may cover the paint is soon scratched 
or bitten off. 

The preceding enumeration of regulations favour- 
able to a young baby, as well as those that follow, 
may seem to some readers as only applicable to 



NURSERY HYGIENE 85 

wealthy people. They are, however, applicable both 
to wealthy people and to intelligent people of little 
means. I have endeavoured to call attention to the 
ideal which should be approached as nearly as condi- 
tions will allow. Intelligent women who do their 
own housework may carry out most of these pro- 
visions, but can do it only by making the baby their 
first duty. The result of this attention to the baby 
during the first year of life amply repays for the sac- 
rifice it involves, for following the prescribed routine 
and keeping the baby well involves much less wear 
and tear than troublesome days and sleepless nights 
associated with the care of a baby that is badly man- 
aged, spoiled or sick. 

The bowels. — After the first feeding, at some con- 
venient hour early in the morning, before prepara- 
tion is made for the bath, an attempt should be made 
to obtain a movement of the bowels. 

Nothing about the baby is more important for the 
mother to watch than the character of the baby's 
stools. 

Quality of feces. — The normal stool of the healthy 
baby is yellow, smooth, shiny, and soft, and of normal 
odour. 

Colour. — The colour of the normal stool of the 
baby if breast fed is orange yellow, while when fed 
on modified milk it is usually canary yellow. A nor- 
mal stool after exposure to air often turns a green or 
grey colour. It is changed by slight indigestion to a 
brown, and as the condition becomes worse to a 
bright green. A white or clay coloured stool indi- 



86 ELEMENTS OF PEDIATRICS 

cates sometimes too much fat in the food or an in- 
sufficient admixture of bile. This latter condition is 
rarely seen in infancy, but when present is usually 
accompanied by vomiting and jaundice. A stool 
may be dark in colour, from the administration of 
iron or bismuth or the presence of old blood, or be 
stained red from the presence of fresh blood. 

Smoothness. — By the smoothness of the normal 
stool we mean its homogeneous appearance, like that 
of butter. When digestion is imperfect, there ap- 
pear small or larger white masses called curds, vary- 
ing in size from a pin-head to that of a French pea. 
These masses have usually a lighter colour than the 
rest of the movement, and are composed of fats, 
fatty acids, and soaps held together by a skeleton 
curd of undigested milk, and indicate that part of the 
food taken by the child has not undergone digestion. 
I believe curds usually indicate protein indigestion. 
The smoothness of the stool may further be inter- 
fered with by the presence of mucus. This mucus 
is usually a secretion of the walls of the intes- 
tine, and due to irritation and inflammation of it. 
The presence of mucus is often evident on inspect- 
ing a stool. Sometimes its presence can only be 
demonstrated by pressing the stool between two 
layers of a diaper and then drawing them apart. 
The strings of mucus will stretch from one surface to 
the other. The possibility of respiratory mucus in 
the stool should be borne in mind. 

Shininess. — The shiny character of the baby's stool 
is due to the fat contained in it. Babies are fed much 



NURSERY HYGIENE 87 

more fat than is needed for their nourishment or 
absorption, this excess of fat being desirable in 
favouring free movements from the bowels, and pro- 
tecting the child from constipation. A hard, dry 
stool may indicate a need of more or less fat or more 
water in the food, or more food. 

Softness. — Any deviation from the softness of the 
stool should call for some modification of the diet. 
If the stool is too hard, as has already been said, 
some modification of the child's food should be made 
by the physician, or a laxative given, in order to 
ameliorate this condition. Loose stools may be as- 
sociated with too much food or too little or a de- 
fective formula or an intestinal infection. 

Odour of stools. — While the normal odour of the 
stool may be variable it may be stated that a stool 
should not have a sour or a cheesy or a markedly 
putrefactive odour. 

Quantity of stool, — A stool of a properly fed baby 
should contain a certain amount of waste. Stools 
that are only stains on the diaper usually indicate 
too little food. This is an important indication in 
breast fed babies who are not gaining. 

Frequency of movements. — In infants during the 
first weeks of life two or three normal stools during 
the day are frequently seen, but, as the child becomes 
older, usually but one or two occur each day. 

Before the morning bath an attempt should be 
made each day to procure a movement of the bowels 
of the child, in a vessel used for that purpose. 
Usually this is easily accomplished by a little 



88 ELEMENTS OF PEDIATRICS 

patience and the use of the following method, and 
this method may be begun when the baby is only a 
month old. 

Have a low round bowl with a simple curved edge, 
and a box of small glycerine suppositories. Each 
morning before the bath have the baby held over the 
bowl with its thighs well flexed on its body, and have 
inserted just through the sphincter of the rectum a 
small glycerine suppository, those of somewhat the 
size and shape of a cigarette, termed infant size, 
answer very well. If this procedure does not soon 
procure a movement from the bowels, the suppository 
may be pushed all the way in and left there, and the 
baby still held in the same position for a few mo- 
ments longer. Usually the simple irritation of the 
suppository in the rectum is sufficient to induce ac- 
tion. After some days the baby will make an effort 
to have its bowels act as soon as an attempt is made 
to introduce a suppository, later the mere position of 
the baby on the bowl with its thighs flexed is sufficient 
to induce an action of the bowels. By faithfully pur- 
suing this method regularly, day after day, it is pos- 
sible in most babies to establish a regular habit very 
early in life. 

Habit in micturition. — In a similar manner a child 
may be taught the control of the sphincter of the 
bladder by placing the child on a vessel previous to 
such time as it is usually found wet. No attempt 
should be made to control nocturnal incontinence 
until the child is kept dry all day. 

The bed wetting of older children is in some cases 



NURSERY HYGIENE 89 

a difficult habit to control. In these resistent cases 
sources of reflex irritation, such as adenoids, phim- 
osis, or adherent prepuce shutting in masses of 
smega, should be eliminated and treatment under- 
taken by the systematic use of all the various in- 
fluences one can bring to bear to aid the child in 
keeping dry. Mechanical helps can be afforded by 
diminishing the amount of water taken after the mid- 
day meal, keeping the supper rather dry, and by 
elevating the foot of the bed three or four inches, 
which relieves the pressure of accumulated urine on 
the neck of the bladder. The co-operation of the 
child must be sought and suggestion used as the child 
is going to bed at night, by strict injunction and by 
emphasis on the uncleanliness of the habit, and as an 
aid to co-operation a prize may be offered for good 
behaviour. An effective aid is often obtained by 
having a large calendar hung in a conspicuous place 
on the wall of the nursery, each page having the days 
of one month, and pasting on the calendar a gold star 
as the result of a good record and a black star when 
the child has wet itself. Some article the child 
really wants may be given for a sufficient row of 
gold stars. These are the really effective measures. 
Belladonna given at bed-time still further aids in 
the cure. 

The bath. — The most convenient arrangement for 
bathing babies is a bath tub made of rubber cloth, 
hung in a frame which stands about three feet high 
from the floor. This is a convenient height for the 
nurse, and when not in use, the tub may be folded up 



90 ELEMENTS OF PEDIATRICS 

and put out of the way. In preparation for the bath 
a chair should be arranged for the nurse, with the 
bath tub on one side and a table containing the neces- 
sary toilet articles on the other. A full bath should 
be given every morning, after the navel is healed, 
unless there is some contraindication, such as a gen- 
eral eczema, or a bad reaction after the bath, as 
shown by cold extremities or cyanosis. The bath 
should be given at first at a temperature of one hun- 
dred degrees Fahrenheit. 

The child should be put in the bath, taken out and 
soaped with castile or other clean, non-irritating 
soap, and again rinsed in the tub, and then dried 
thoroughly. Very young babies should be bathed 
quickly in a warm room. 

These baths should be continued daily, with a grad- 
ual reduction of the temperature of the water to 
seventy degrees Fahrenheit when the child is one 
year old, if the child shows a good reaction after the 
use of water at this temperature. A bath that leaves 
a child with cold extremities is too cold or too long 
continued for that particular child. 

Care of the teeth. — While mouth washing is un- 
necessary and often harmful, care of the teeth from 
the time the first teeth appear is very important. 
For this purpose a small, soft tooth brush and some 
cleansing tooth paste or powder should be used twice 
a day. 

As children grow older and brush the teeth them- 
selves, care must be taken that this is done thor- 
oughly, for not infrequently one finds the front teeth 



NUBSERY HYGIENE 91 

fairly brushed, with the molars entirely neglected. 

The importance of this is appreciated after notic- 
ing the condition of the teeth generally found in cases 
of rheumatic heart disease, where extensive decay of 
the teeth usually precedes the attack. 

Teeth that are decayed, even if they are the tem- 
porary teeth, should be immediately filled or pulled, 
for decaying teeth react on the general health of the 
child. 

Weighing. — Either before or immediately after 
the bath, the baby should be weighed. This should 
be done every second or third day in babies under 
three months of age, and once a week thereafter 
during the first year. 

Rest. — After the bath and dressing, the child is 
allowed to rest, and this rest may be taken at home, 
but preferably out of doors in a baby carriage. Most 
babies sleep better in a baby carriage out of doors 
than anywhere else, during the day. Some babies, 
after crying incessantly in the house, will imme- 
diately go to sleep on being taken out in their car- 
riages. Babies who cannot be taken out should be 
placed before an open window. They should never 
be allowed to fall asleep in the nurse's arms or rocked 
in cradles, or on rocking chairs, as both these 
methods are no more efficient than other methods and 
are apt to become a nuisance, because the children 
will soon demand rocking before going to sleep. All 
children require a great deal of sleep. Babies should 
have all the sleep they will take and children, even as 
they grow older, and until they are ten years old, are 



92 ELEMENTS OF PEDIATRICS 

benefited by at least one interval of sleep during the 
day. 

Fresh air. — Babies born in winter may be allowed 
out of doors on the first mild day after they are a 
month old, while those born in summer may be out 
when only a week old, if the weather is favourable, 
that is, with only a moderate wind and no dust. 
Damp days will not hurt them. On very windy days 
and dusty days they should never be allowed out. 
When it is not practicable to take a baby out of doors 
a modification of the same fresh air may be obtained 
by wrapping the baby up well, closing the doors of 
the room, and opening the windows. As soon as the 
baby is allowed out, it should be out twice on every 
favourable day for several hours each time. Even 
in fairly cold weather, babies may be kept out with- 
out injury, if well wrapped. 

It is often possible in cities to use the roof of an 
extension or the roof of the house for keeping babies 
and children in the fresh air. The roof of an exten- 
sion, if it happens to be on the same floor with the 
nursery is most convenient. It should have a suffi- 
ciently high railing around it and it must be fre- 
quently cleaned in order to remove dust that 
rapidly accumulates. Children may be conveniently 
put on such a roof to play while the nursery maid 
attends to the preparation of the food and to the 
other work that is necessary to be done before she is 
able to go out of doors herself. Where the roof of 
the house is used, it should be enclosed, if possible, on 
the north side. This protects the roof from the cold 



NURSERY HYGIENE 



93 



north winds and provides a room for play during 
rainy weather, as well as a protection for the toys 
that are nsed on the roof. For older children, in 
stead of a railing around the roof a complete cage is 
of advantage. This allows the children to play ball 
or foot-ball without having the ball drop into the 
street below. It is sometimes desirable as well that 
the openings of the chimney and vent pipe outlet 
from the sewer line be raised. 

Change of air from one part of the country to 
another has the same tonic effect on babies that it has 
on adults, and in summer, babies who will not do well 
in cities often improve remarkably on being taken to 
some healthful country resort. 

Exercise. — Exercise is as important an element in 
contributing to the health of the infant or young 
child as it is in the adult, and this should be remem- 
bered from the very beginning of an infant's life. 
Although during the first weeks of life the baby 
should sleep twenty hours out of the twenty-four, 
when awake it should have ample opportunity to 
move freely its legs and arms, and, therefore, all 
clothing and methods of carrying the baby which in- 
terfere with the freedom of the motion of the arms 
and legs or with the descent of the diaphragm inter- 
fere at the same time with the good health of the 
child. 

Baby jumper. — When the baby is able to sit alone, 
usually at the seventh month, a contrivance known 
as the baby jumper is useful for the further de- 
velopment of the legs without making it necessary 



94 ELEMENTS OF PEDIATRICS 

to carry the weight of the body. In this baby jumper 
the baby sits in a saddle within a wooden circle, 
which is supported by a large hoop on castors. 
This saddle is adjusted so that the baby's feet may 
touch the ground. The baby soon learns to propel 
this from one part of the room to another, the lower 
and larger hoop being of too great circumference to 
allow the baby to get close to things near the wall or 
to get through an ordinary door. 

Nursery fence. — Another contrivance particularly 
valuable at this time is called the nursery fence, 
which makes an enclosure some two feet high around 
a square, — the enclosed space should be as large as 
the room will accommodate. A clean sheet is placed 
on the floor within the enclosure. The baby can then 
be put on the sheet, with soft dolls or other harm- 
less playthings and left to amuse itself. Here babies 
learn to crawl in getting things they cannot reach 
and later holding on to the fence will pull them- 
selves up on their legs. These enclosures are, there- 
fore, of value in obtaining exercise for the babies 
as well as in teaching them to amuse themselves 
and to help themselves. 

At the eighth month, most children begin to crawl, 
and at the twelfth month can stand holding on to 
some piece of furniture, while at the fifteenth month 
they are usually able to stand by themselves and take 
a few steps. Caution must be observed that at this 
period they are not allowed to over-exert themselves. 
Walking for them, while a possibility, is hard work, 
a very moderate amount being sufficient to tire them. 



NURSERY HYGIENE 95 

It is not unusual to see little children in the streets, 
dragged along by their mothers, half crying, and evi- 
dently suffering severely from fatigue. Such exer- 
cise not only tires the child, but is apt to cause de- 
formities of the feet. The exercise children over 
two years old need is that obtained when playing 
with other children, exercise with recreation and 
spasmodic intermittent exercise. Young children 
can run hard for a moment or two and such running 
uses their muscles, inflates their lungs and does them 
much good. Roller skates, ice skates, and tricycles 
should be allowed young children, while for older 
healthy children tennis is to be insisted upon, or, as a 
compromise, golf. Boys should be allowed baseball, 
football, swimming and all healthy out of door sports 
for several hours every day. 

The feet. — The feet of babies should receive con- 
siderable care, the arch of the foot being easily 
broken down, so that by too much, too severe, or too 
prolonged exercise, a flat foot may be early produced. 

The shoes should be of proper size, so that they 
may fit snugly, especially around the instep and the 
sides of the heel, without causing undue pressure or 
crowding of the feet. The toes should lie flat and 
separate. The shoes should be made in rights and 
lefts, so that each shoe may be fitted to the shape of 
the foot and should be so shaped as to support the 
instep. Ordinary shoes which are cut off on the 
inner side, thus pressing the great toe in, cause an 
inflammation of the metatarso-phalangeal articula- 
tion, which ultimately results in what is ordinarily 



96 ELEMENTS OF PEDIATEICS 

known as a bunion. Shoes which are too large or too 
loose, or too tight, on the other hand, may cause 
corns, even in little children. 

Care of genitals. — In the care of the genitals it is 
quite as important that cleanliness be used as in 
other parts of the body. Such cleanliness is impos- 
sible in a male baby with a phimosis. The simplest 
means of placing the male genital organs in a condi- 
tion of cleanliness is by circumcision. With the re- 
moval of the foreskin the openings of the glands 
which secrete the smegma are exposed so that this 
smegma is readily removed. At times, however, cir- 
cumcision is not done so completely but that adhe- 
sions may take place and in circumcised children we 
may still find irritation from enclosed smegma. Cir- 
cumcision is rarely necessary, as even -the tightest 
foreskin may be stretched and soon retracts readily, 
so that retraction of the foreskin is in a large ma- 
jority of cases the only interference needed. After 
retraction, however, adhesions will occur so that in 
babies a breaking down of these adhesions is neces- 
sary two or three times a year, in older children less 
often. Unless the smegma is removed as excreted it 
will be a cause of irritation which will annoy the 
child and may lead to masturbation, while the decom- 
position of the smegma may give rise to a balanitis. 

In female babies, although a similar condition of 
adhesions around the clitoris is usually present 
there is less secretion of smegma and this condition 
is ordinarily overlooked unless the irritation is suffi- 
cient to cause the habit of masturbation. Masturba- 



NUBSEBY HYGIENE 97 

tion by means of thigh rubbing is not very uncommon 
in female babies under one year of age, and is a 
habit that should be controlled as promptly as pos- 
sible. The cause of this habit is apparently adhe- 
sion of the prepuce to the clitoris and irritation of 
the enclosed smegma, so that where symptoms of irri- 
tation occur these adhesions should be promptly 
broken down and the clitoris made free. Inasmuch, 
however, as the adhesions will quickly re-form, unless 
a circumcision is done, all masturbating female in- 
fants should, I believe, be put under an anesthetic 
and be well circumcised by some surgeon accus- 
tomed to perform this operation. Even after cir- 
cumcision, however, it may be necessary to break 
down any adhesions that have formed. 

Protection from infection. — The prevention of dis- 
ease in babies is, for the most part, a matter of 
proper diet, good air, scientific cleanliness, and 
avoidance of contagion. Most sickness is due to con- 
tagion from other people, receiving the sputum ex- 
pelled from the mouth of other persons, in talking or 
coughing or sneezing, or to eating or drinking or in- 
halation of dirt with the bacteria that accompany it. 
Many babies are made ill by dirty water ; still more 
by dirty milk • some by dusty air, and many by dirt 
from the floors, which gets into their mouths by 
means of their fingers. All babies are attracted by 
unusual objects and all babies put everything pos- 
sible into their mouths. Babies rarely get sick from 
too little clothing or from exposure to fresh air. 

It is possible, during the first years, to protect 



98 ELEMENTS OF PEDIATEICS 

babies to a considerable extent from snch uncleanli- 
ness, thus, at the same time, protecting them from 
acute diseases, and particularly from intestinal dis- 
eases. 

During the first months of life, a baby should have 
its head kept continually on a clean pillow case, 
even when taken in the mother's arms the pillow 
should be transferred with it. Later, as it begins 
to crawl, a nursery fence (page 94) may be used to 
prevent a child from getting into dirt. 

After the first year, when it is able to run about, 
this contamination of dirt can only be avoided by 
warning the child, and punishing it if it puts its 
fingers into its mouth. 

Thumb sucking. — All babies suck their thumbs as 
soon as they have sufficient intelligence to put them 
into their mouths. This habit is objectionable be- 
cause it introduces into the mouth any dirt or bac- 
teria that may be on the thumb. It deforms the 
mouth, it presses forward the upper incisor teeth 
and makes the thumb sore. It is, therefore, desir- 
able to stop the habit as soon as possible. This may 
be accomplished by cheesecloth mits stuffed with ab- 
sorbent cotton, but as they are very warm in summer, 
ventilated aluminum spheres made for the purpose, 
which may be attached to the wristband of the dress, 
are usually preferable. 

Kissing. — A baby is subjected to a great deal of 
maltreatment by affectionate, but uninformed rela- 
tives and friends, and probably one of the worst of 
these is the habit of the mother and her friends of 









NUBSEBY HYGIENE 99 

constantly kissing the baby. It has already been 
shown that a baby should be kept, as far as possible, 
isolated from bacteria that may be harmful, and the 
months of all persons are full of a large variety of 
bacteria, and the months of healthy people have been 
repeatedly found to contain virulent germs of diph- 
theria, and other diseases. It is thus evident that 
kissing is always a bad habit, and that it should 
never be imposed on babies. If a mother or father 
must kiss their child, they should kiss it on the cheek 
and give it a very dry kiss. 

School. — Physicians are often consulted by intelli- 
gent parents concerning the age when children may 
be sent to school ; the work they should do there ; and 
the number of hours they may remain ; all most im- 
portant matters bearing on the health and develop- 
ment of the child. 

A well developed child may be sent to a good kin- 
dergarten when three years old. A child at this age 
has no adaptation for prolonged application, so that 
the teaching should be done in the form of games 
and exercises, giving alternately short periods of 
active exercise and rest. 

The teacher in the kindergarten should be particu- 
larly well qualified, both by nature and by education, 
for her work, so that she may enter with enjoyment 
into the games. The kindergarten teaches children 
accurate observation, teaches them how to use their 
hands and feet, and teaches them also how to get 
on with other children. The exercise provided will 
occasionally cure an obstinate case of constipation. 






100 ELEMENTS OF PEDIATRICS 

Dull children. — Children who appear dull at school 
should receive special individual attention, and a 
laboratory for complete physical examination should 
be established in connection with all schools. Dull 
children, then, should be carefully examined to deter- 
mine the cause of their backwardness. Some of 
these children are found to be eye-minded, that is, 
they can understand and remember only what they 
see, and when taught by reading are equal to their 
school-mates. Other dull children are found on 
examination to be ear-minded, that is they cannot 
learn well by seeing but only by hearing, and these 
again, when taught with reference to this peculiarity, 
are equal to their fellows. Others appear dull 
because they are deaf, and their deafness may be due 
to the presence of wax in the ears or adenoid growths 
in the pharynx, on the removal of which their hear- 
ing is restored, and 'they are found to be as bright as 
their schoolmates. The early correction and proper 
treatment of any of these troubles is most im- 
portant for the proper development of the child. 
All children have a tendency to be what they are 
considered to be, so that a constant position at the 
foot of a class due to one of these troubles, will soon 
injure the child permanently. Mentally deficient 
children should have special classes. 

Defective children. — Mentally deficient children 
may belong to one of several types, the most com- 
mon being that due to cerebral hemorrhage at birth, 
while the Mongolian type of idiocy and the micro- 
cephalic and hydrocephalic types are frequently 



NUESEBY HYGIENE 101 

seen. All of these obtain little benefit from treat- 
ment. On the other hand, the cretin, whose condition 
is due to lack of thyroid extract, may, if diagnosti- 
cated early, be much benefited by proper treatment. 



CHAPTEE VIII 

DAILY REGIME 

Regime for a baby under three months. — The daily 
regime of a baby depends upon its age, as well as 
somewhat on the individual baby itself. A baby 
under three months (Figure 27) will usually wake 
promptly at six a. m. for a bottle. If it sleeps later 
it may be allowed to do so, but after its bottle it 
should go to sleep again. It should, however, be 
wakened at eight-thirty a. m. and an effort made to 
secure a movement of the bowels by the method in- 
dicated on page 87 if they have not already moved. 

The baby should then be allowed to lie naked in a 
warm place for ten minutes and swing its arms and 
legs. It is then bathed and dressed in time to be 
ready for the bottle at nine o'clock. The baby 
should sleep from nine-thirty until twelve, at which 
time another bottle is given and after which it should 
sleep again until three o'clock. From five-thirty to 
six p. m. the child should be exposed without clothing 
in a warm room as it was in the morning. It should 
then be prepared for bed and after the six o'clock 
feeding should sleep until the last bottle is given at 
ten o'clock. At each time the baby is awake the 
diaper should be changed if it is wet. From ten- 
thirty p. m. to six a. m. the baby should sleep. The 

102 



DAILY EEGIME 103 

only disturbance that the child should have at other 
times should be to change a wet diaper. 

FIGURE 27. 

DAILY REGIME 

BABY UNDER THREE MONTHS 

6 :00 a. m. Bottle. 

6 :00-8 :30 a. m. Sleep. 

8 :30 a. m. Effort to secure movement of 

bowels. 

8 :40 a. m. Allow to lie on back naked and 

exercise arms and legs. 

8 :50 a. m. Bathe and dress. 

9 :00 a. m. Bottle. 

9:30-12 m. Sleep. 

12:00 m. Bottle. 

12 :30-3 p. m. Sleep. 

3 :00 p. m. Bottle. 

5 :30-6 p. m. Exercise. 

6 :00 p. m. Bottle. 

6 :30-10 :00 p. m. Sleep. 

10 :00 p. m. Bottle. 

10 :30-6 :00 a. m. Sleep. 

Regime from three to six months. — The regime 
from three to six months (Figure 28) is similar to 
that of the first three months, excepting that orange 
juice is administered at eight-twenty a. m. 

FIGURE 28. 
DAILY REGIME 

CHILD THREE TO SIX MONTHS 

6 -.00 a. m. Bottle. 

8 :20 a. m. Teaspoonful to a tablespoonful of 

orange juice. 



104 ELEMENTS OF PEDIATRICS 

8 :20 a. m. Movement of bowels. 

8 :30 a. m. Exercise naked. 

8 :50 a. m. Bathe and dress. 

9:00 a.m. Bottle. 

9:30-12:00 M. Sleep. 

12:00 m. Bottle. 

12:30-3:00 p.m. Sleep. 

3 :00 p. m. Bottle. 

5 :30-6 :00 p. m. Exercise naked. 

6 :00 p. m. Bottle. 

6 :30-10 :00 p. M. Sleep. 

10 :00 p. m. Bottle. 
10 :30 p. M.-6 :00 a. m. Sleep. 

Regime for sixth month to first year. — At the sixth 
month, however. (Figure 29), a considerable change 
is usually advisable. The baby is then put on f our- 

FIGURE 29. 
DAILY REGIME 

CHILD SIX MONTHS TO ONE YEAR 

6 :00 A. M. Bottle. 

9 :00 A. M. Orange juice, tablespoonful to juice 

of one orange. 

9 :10 a. M. Move bowels. 

9 :15-9 :45 A. M. Allow to exercise naked. 

9 :45 a. m. Bathe and dress. 

10 :00 a. m. Feeding. 

10 :30-2 :00 p. m. Sleep. 

2:00 p.m. Feeding. 

5 :00-6 :00 p. m. Exercise. 

6:00 p.m. Feeding. 

6 :00-10 :00 p. M. Sleep. 

10 :00 p. M. Bottle. 
10:30 p.m. to 6 a.m. Sleep. 



DAILY EEGIME 105 

hour feedings, the feedings thus coming at six and 
ten a. m. and two, six and ten p. m., and the orange 
juice is given at nine a. m., after which the bowels are 
moved. 

After that a period of one-half hour may be given 
to exercise without clothing. At this period the 
child will take rather less sleep and during the latter 
part of the afternoon it is well for it to remain 
awake, so that it may be ready for sleep after the six 
o'clock bottle. During this period the character of 
the food also changes somewhat and by the eighth or 
ninth month, rusk, soup, and cereal fed by a spoon 
may be added, perhaps with some vegetable which 
may first be added to the soup. 

Regime during second year. — During the second 
year the evening feeding may be omitted, and the 

FIGURE 30. 
DAILY REGIME 

SECOND YEAR 

6 :30 to 7 a. m. Rise. Drink glassful of water. 

Bathe. Dress. 

7 to 7 :30 a. M. Breakfast. 

8 :00 a. m. Movement of the bowels. 
8 :15 to 10 a. m. Out of door play. 

10 :00 A. m. Bottle. 

10 :30 to 1 :30 p. m. Sleep. 

1 :30 p. m. Glassful of water. 

2 :00 P. m. • Dinner. 

3 to 5 :30 p. m. Out of door play. 

5 :30 p. m. Glassful of water. 

6 :00 p. m. Supper. 

7 p. m. to 7 a. m. Sleep. 



106 ELEMENTS OF PEDIATRICS 

orange juice transferred to the two o'clock feeding. 
It is also customary to give a mixed feeding when the 
child arises and only a bottle later in the morning. 
The amount of sleep the child will take during the 
day is less. (Figure 30.) 

The first meal at seven or half past in the morning 
would correspond to the meal previously given at 
ten o'clock in the morning, the baby having been 
bathed and dressed before breakfast. Immediately 
after breakfast the child should be placed on a chair 
for the movement of the bowels, and after this taken 
out of doors, or placed in a nursery fence, where it 
may have facilities for walking and standing. A 
return to the house must be made for the ten o 'clock 
bottle, after which the baby should sleep out of doors 
in its carriage, or before an open window, until the 
two o'clock feeding. A child of this age rarely 
sleeps after this feeding. It should then be taken 
out and when brought in the house it may be un- 
dressed and allowed to exercise without clothes for a 
half hour before supper. After supper it should 
immediately be put in a dark room and left to sleep. 

Regime after the second year. — After the second 
year (Figure 31) but three meals a day should be 
given; a breakfast in the morning after dressing; a 
substantial meal at twelve o'clock and a supper at 
five or five-thirty. 

The child now needs more exercise and should be 
allowed to run and play games that require running. 
The exercise should be active and intermittent, and 
not persisted in long enough to cause marked fatigue. 



DAILY EEGIME 107 

These children will rarely sleep during the morning, 
but are usually ready for a nap after the midday 
meal, and this nap should, if possible, last from one 
to two hours. The bed-time should be immediately 
after a six o'clock supper. 

This regime is applicable to all children up to ten 
years of age, excepting that with each increased year 







FIGURE 31. 




DAILY REGIME 




AFTER 


THE SECOND YEAR 


7:00 a.m. 




Rise. Drink glassful of water 
Cool bath and rub. Dress. 


7 :30 A. M. 




Breakfast. 


8 :00 A. m. 




Move bowels. 


8:30 to 11:30 


A. M. 


Out of door play. 


11:30 A.M. 




Drink glassful of water. 


12:00 Noon. 




Dinner. 


1 to 3 P. M. 




Sleep. 


3 to 5 :30 p. m. 




Out of door play. 


5 :30 p. m. 




Glassful of water. 


6 :00 P. m. 




Supper. 


7 P. m. to 7 A. 


M. 


Sleep. 



of age somewhat more exercise is required and some- 
what less sleep. The after dinner nap should be per- 
sisted in up to the tenth year in all frail children, but 
must be dispensed with in some robust children. 

The exercise may be varied by the use of roller 
skates, ice skates, tricycles, bicycles, and tennis. 

An interference with this regime occurs when the 
child goes to school, but for little children there is 
only a morning session and this allows them a full 



108 ELEMENTS OF PEDIATRICS 

afternoon in which to be out of doors. If the school 
is an out of door school or a proper kindergarten, 
giving the children plenty of exercise, it may leave a 
very good regime. 

As soon as the child returns to school for an after- 
noon session the after-dinner nap must be abandoned. 



CHAPTEK IX 

VACCINATION 

Definition. — Vaccination is the inoculation of the 
germs of smallpox (as yet unknown), modified by 
their passage through a less susceptible animal. 

Time for first vaccination. — Children should, as a 
rule, be vaccinated before the end of the first year. 
It has been a routine practice with many physicians 
to vaccinate the baby within a month after birth, and 
indeed, if the baby is doing absolutely well, there is 
no objection to this practice. Often, however, dur- 
ing the first three months, there is some difficulty in 
feeding babies, and keeping them well, so that it has 
seemed to me better, as a usual practice, to vaccinate 
babies when they are about three months old, if at 
that time the weather is not hot and the baby is in 
good health. All girl babies in good health should be 
vaccinated before the eighth month for reasons given 
below (page 111). 

Virus. — The virus to be used in vaccination is the 
bovine virus, which is the only sort that is now com- 
monly used, and should be one of the glycerine 
preparations put up in capillary tubes, the old- 
fashioned points of virus being often dirty and sub- 
ject to contamination from handling. The glycerine 
preparation, on the other hand, increases in activity 

109 



110 ELEMENTS OF PEDIATEICS 

during the first three months that it is stored in a 
cold place, while the contaminating bacteria which 
were present in the virus as taken from the calf, are 
very much lessened by the prolonged cold and the 
presence of considerable proportion of glycerine. 
This virus being sealed in capillary tubes is not con- 
taminated by handling, but is subject to deterioration 
on keeping, owing to a loss of virulence in the small- 
pox organism, so that a virus which when three or 
four months old is very active, may when seven 
months old be of little value for inoculation. 

Of the different preparations of virus, that of the 
New York Board of Health is usually preferred in 
New York, since we are familiar with the precautions 
that are used in preparing it, and have confidence in 
the experts who have control of its preparation. 

Site for vaccination. — The point of election for 
vaccination in babies and young children differs from 
that in adults. In adults we vaccinate on the upper 
part of the arm, below the insertion of the deltoid, 
because vaccination on the lower extremities in 
adults is apt to do badly unless the person is kept in 
a horizontal position. In babies, the circulation 
being more active, and the leg not being a dependent 
part, vaccinations on the legs do perfectly well, as a 
rule. We thus avoid the disfigurement of the arm 
and, at the same time, find the position easier to 
get at and to care for afterwards. In children 
leg vaccinations should be watched and the child 
put to bed if much inflammation ensues or if the 
inflammation travels up and the inguinal glands 



VACCINATION 111 

become involved. The point of election for vaccin- 
ation in infants is over the upper end of the tibia, on 
its outer surface. In this position the dressing is 
easily retained, and the vaccination may be examined 
by simply lowering the stocking and perhaps pulling 
up the drawers. 

All girls should be vaccinated before the eighth 
month, at which age they usually begin to crawl 
and would break a scab over the upper end of the 
tibia. Girl babies over eight months of age, who are 
vaccinated, should be vaccinated on the lower outer 
portion of the thigh, and care must be taken that the 
vaccination is not contaminated by soiled diapers. 
Boys may be vaccinated on the arm below the inser- 
tion of the deltoid muscle. 

Method. — In vaccinating we are careful to cleanse 
the skin, usually with alcohol, which quickly evapor- 
ates, since the presence of other antiseptic solutions 
may injure the small-pox germs which we in- 
oculate. 

For scarification a needle may be used, but it is 
objectionable, as it too readily makes a bleeding 
wound and the blood may wash away the virus, thus 
causing a negative result. A von Pirquet scarifica- 
tor or a jeweller's screw-driver makes the best in- 
strument, for it provides an oozing surface without 
bleeding. (Figure 32.) 

The two ends of the capillary tube, containing the 
virus, are broken off and after sterilisation in a flame 
a little rubber bulb is passed over one end and by 
means of pressure over the hole at the end of it the 



112 ELEMENTS OF PEDIATRICS 

virus may be driven out and dropped on the area for 
scarification. The jeweller's screw-driver, which 
has been sterilised in .the flame, is now rotated in the 
virus until an oozing surface is obtained. 




Making Scarification. 




Ejecting Virus from Tube. 

FIGUKE 32. 
Vaccination. 

Protection. — It has formerly been the practice to 
let the virus dry on the skin, and then pull the 
clothing over it and allow the case to pass from ob- 
servation. It has been found that many of these 
vaccinations, in very susceptible infants, have become 
contaminated through the rubbing into the wound of 
septic bacteria from the clothing or finger nails, thus 
causing considerable irritation, and in some cases 



VACCINATION 113 

septicemia and death. It has, therefore, seemed ad- 
visable to treat vaccinations in the same cleanly man- 
ner as other surgical wounds, and also to protect 
them from contamination. The common surgical 
dressing of cotton or gauze and a bandage has proved 
impracticable, since it softens the scab and allows 
exudation of serum from the vaccination, which irri- 
tates the surrounding skin and quickly soils the dress- 
ing. On this account, ventilated protectors have been 
adopted, and the best, I believe, at the present time, 
is the little celluloid cap held down by zinc oxide 
plaster. This cap has the advantage of being trans- 
parent, so that the vaccination may be watched, and 
the zinc plaster that retains it is not very irritating. 
Before the site of vaccination becomes inflamed the 
celluloid cap should be removed because it interferes 
with the peripheral circulation and makes a taking- 
vaccination very much more severe than it should be. 
It ought, therefore, to be replaced by three or four 
thicknesses of gauze about two inches square, held in 
place by two narrow strips of zinc oxide plaster. 

Period at which they begin to take. — Primary vac- 
cinations very regularly show some evidence of tak- 
ing in five days, and by the sixth day there is usually 
a vesicle surrounded by a red areola. 

The inflammation continues to increase until about 
the twelfth day, when there is usually an elevated 
vesicle one-half to three-fourths of an inch in 
diameter surrounded by an area about two inches in 
diameter of redness and induration. Often small 
vesicles appear in the inflamed area. The thirteenth 



114 ELEMENTS OF PEDIATRICS 

day there is usually some subsidence of the inflamma- 
tory reaction and by the fourteenth day the vesicle 
should be drying and the inflammation materially 
lessened. It is usually four weeks before the scab is 
off and t during this period no full bath should be 
given. 

If a vaccination on the leg takes severely or if 
there is an enlargement of the lymph nodes of the 
groin on that side or red streaks running up the leg 
on that side it is necessary to keep the child in a 
horizontal position and sometimes wet dressings 
must be applied to the groin but not to the vac- 
cination. 

In vaccinating babies the operation is rendered 
painless if provision is made for some unusual noise 
at the time the scarification is made. A tin can and 
an iron spoon make a good combination for this pur- 
pose. 

Revaccination. — All children who have not pre- 
viously been vaccinated should, if a negative result is 
obtained be promptly revaccinated by a more viru- 
lent virus, that is, a fresh virus. This can be ob- 
tained from the maker of the virus who will supply 
one that has had a shorter period of storage. After 
the first vaccination has taken, subsequent vaccina- 
tions are liable to be followed by negative results, 
and when they do take are much more irregular in 
their course. 

Revaccination should take place every five or 
seven years, or whenever there may be an epidemic 
of small-pox. 



CHAPTER X 

TYPHOID IMMUNISATION 

Protective treatment against typhoid fever is com- 
ing into general use. This consists in injecting into 
the subject a large number of dead typhoid bacilli. 
The efficiency of this treatment has been well demon- 
strated in armies. In epidemics of typhoid fever 
spread by milk, children are the most frequent vic- 
tims, while in other epidemics of the disease young 
adults predominate. It is, therefore, important that 
the protection be given in childhood if typhoid fever 
is prevalent. The immunity lasts only two years, so 
that reinoculation must take place at intervals of 
two years unless the subject is found to have a posi- 
tive Widal reaction. 

Intervals between injections. — The treatment con- 
sists of three injections at intervals of five to ten 
days. The first consists of five hundred million dead 
typhoid bacilli and the second and third of a thou- 
sand million. Each injection is followed by a consti- 
tutional and local reaction. 

Reaction. — The constitutional reaction is most pro- 
nounced during the first twelve hours after the injec- 
tion and consists in malaise, headache, nausea, et- 
cetera, while the local reaction consists in redness, 
tenderness and swelling for an area two or three 

115 



116 ELEMENTS OF PEDIATRICS 

inches in diameter arcund the injection and this lasts 
for two days. 

The injections are best given at about four- thirty 
p. m., so that the constitutional symptoms are most 
severe at night while the subject is asleep. 

Method. — For giving the treatment a set of three 
small flasks is obtained, each containing a sufficient 
number of bacilli for one injection. In the New 
York Board of Health set the five hundred million 
dose for the first injection is in a brown flask, the 
other two in white flasks. The stem of the flask is 
best broken by means of the fingers protected by a 
towel, to avoid being cut by the glass, and the con- 
tents are drawn into a sterilised hypodermic syringe. 
The skin of the arm near the insertion of the deltoid 
is painted with tincture of iodine and through this 
painted skin the needle is thrust. As the needle is 
withdrawn, firm pressure may be made for a moment 
over the skin under which the needle passed and then 
after wiping the point of entrance of the needle with 
sterile absorbent cotton, a small piece of cotton may 
be held in place by a strip of plaster. 

While the reaction to this treatment may be rather 
unpleasant, it gives one for a time a fairly complete 
immunity from a prolonged and severe disease. It 
is very desirable that this treatment become general 
and obligatory, so that typhoid fever may no longer 
be endemic. We have in this treatment a weapon 
which, if thoroughly used, would entirely eliminate 
this severe disease. 



CHAPTEE XI 

FEEDING DURING THE FIRST YEAR 

Importance of intelligent infant feeding. — An ac- 
curate knowledge of the science of infant feeding is 
a most important requisite in pediatric practice. In 
the general care of infants the provision for fresh 
air to breathe, for quiet and for exercise, while most 
valuable for their well-being, are, after all, of far 
less importance than the administration of an appro- 
priate food in proper quantity, at correct intervals, 
for only by proper feeding, combined with good care, 
can one keep children healthy. 

Choice of food. — The food must be carefully 
chosen and in any particular child changes may be 
necessary before a food is found that is both a good 
food for the child's development and at the same 
time sufficiently nourishing to secure for him a gain 
in weight. Having found such a food ; the amount to 
be given must be carefully determined, so that while 
not sufficient to cause vomiting or intestinal disturb- 
ance it may be ample to provide for a proper gain 
in weight. 

The food chosen will, of course, depend upon the 
age of the child, its weight, and its general condition 
of nutrition. 

During the first three to six months a good breast 

117 



118 ELEMENTS OF PEDIATRICS 

milk is usually far superior to any other food. After 
the sixth month, babies will often do better on modi- 
fied cow's milk. 

When babies are under good conditions for obser- 
vation and control, they may usually be weaned and 
successfully fed artificially between the third and 
sixth month, although if a baby is doing well at the 
breast and the mother is in good health, a longer 
period of nursing should be urged. 

When babies are born in poverty it is well to have 
them nursed as long as they do well on breast milk, 
for here it is much more difficult to feed artificially 
with success. These mothers should be instructed 
to have their babies weighed at intervals and if they 
are not gaining, to seek medical advice. 

The different methods of feeding may be tabu- 
lated as follows, and they will be discussed in the 
order in which they are placed in the table. (Figure 
33.) 

FIGURE 33. 

CLASSIFICATION OF INFANT FEEDING 

fa. Mother's milk. 

1. Natural. | b _ mt Nurge _ 

2. Mixed. Breast milk with artificial food. 

3. Artificial. 

Superiority of breast milk. — Breast milk for some 
infants under three months is the only satisfactory 
food. No other milk is, for such infants, so digest- 
able and nourishing, and the mother ? s milk is usually 
preferable to that of a wet nurse, so that, in feeding a 



FEEDING DURING THE FIRST YEAR 119 

young infant, the milk of its mother is by far our first 
choice. And it should be impressed upon every 
mother that in giving birth to her baby she has done 
only half her duty and that she must nurse the baby 
that she has brought into the world until it is able to 
thrive equally well on artificial food. 

Reasons for the superiority of breast milk. — Breast 
milk is a much better food for young infants than 
cow's milk because it is more easily digested, more 
nourishing, is always obtained fresh from the breast, 
and is thus at a proper temperature and is little con- 
taminated with bacteria. Its protein is for the most 
part lactalbumin ; it is in solution and forms in small 
friable curds ; and it contains ferments that are not 
present in cow's milk. 

Almost all mothers have breasts distended with 
milk on the third day after labour, although the 
milk does not flow as freely then as it does later, but 
if we are to nurse the baby at the breast it is neces- 
sary from the third day to have care to keep the 
breasts active. 

Contra-indications to use of breast milk. — Certain 
objections to or difficulties in the use of breast 
milk may arise at this time or soon after. In very 
rare cases the child may be unable to suck because 
the presence of hair lip or a cleft palate interferes 
with the closure of the lips around the nipple or the 
shutting off of the mouth from the nasal cavity dur- 
ing an attempt at sucking. In such cases the only 
way in which the breast milk can be used is by taking 
it with a breast pump and feeding it with a spoon. 



120 ELEMENTS OF PEDIATEICS 

This is a tedious task, and is not likely to stimulate 
good lactation, so that these children must fre- 
quently be fed with a substitute food. 

On the other hand, an abnormality of the nipple of 
the mother may interfere with nursing. The so- 
called depressed nipple, which fails to protrude suffi- 
ciently for the child to grasp it firmly, interferes se- 
riously in some cases with nursing. Fortunately 
this usually occurs on one side only, and in some 
cases the condition may be helped by the use of a 
breast pump to draw the nipple out, or a nipple 
shield, although it is rarely possible to improve con- 
ditions so that the baby can be satisfactorily nursed 
from such a nipple. 

Illness on the part of the mother may interfere 
with nursing, especially if the illness is of such a 
character as to render the child liable to acquire the 
same disease. Tuberculosis, or the acute exan- 
themata, or any serious communicable disease should 
contra-indicate breast feeding, both on account of 
the baby and the mother. It should, however, be 
well understood that lactation is a normal process 
after pregnancy and nursing is not contra-indicated 
simply because the mother is delicate and frail. 

Most women can nurse their babies if properly in- 
structed and controlled. — Having made these reser- 
vations we still have left a large majority of the 
women who give birth to babies and do not nurse 
them. These babies are not nursed, on account of 
lack of secretion in the breast, or in some cases be- 
cause with previous children the mother has been 



FEEDING DURING THE FIRST YEAR 121 

unable to nurse them satisfactorily. It seems prob- 
able from the experience of the writer that nine- 
tenths of these women could nurse their babies if 
properly encouraged and aided by such effective 
measures as we have at hand. This can be done, 
however, only by the persistent use of appropriate 
measures, by careful observation, and by daily rec- 
ords of weight. 

The first two days after birth there is a normal loss 
of weight, amounting usually to about three-fourths 
of a pound, while on the third day the child should 
begin to hold its own and then gradually gain. If 
at the end of a week or ten days the child is not gain- 
ing, accurate information must be obtained as to the 
quality and quantity of breast milk secreted. 

Determination of quantity of breast milk. — The 
quantity of breast milk obtained by the child is read- 
ily determined by weighing the baby immediately be- 
fore and after nursing, no change in the clothing of 
the child being made in the meantime. For this pur- 
pose, a balance scale (Figure 26, page 80), not a 
spring scale, should be used, the latter being inaccur- 
ate, because every movement on the part of the child 
makes a long movement of the indicator. The dif- 
ference between the weight before and after nursing 
will be the weight of the milk taken. If the child is 
weighed before and after every nursing for a day or 
two a fairly accurate estimate may be made of the 
amount of milk the child takes at the breast. 

Quantity of milk necessary. — The quantity of 
breast milk necessary for the support of the child 



122 ELEMENTS OF PEDIATBICS 

depends not only upon the age of the child but upon 
its size and weight; upon the frequency of feeding 
and the quality of the food. Considering, however, 
that the feedings are at such intervals as are here- 
after indicated, that the food is of fair quality and 
that the child is of the average size, it may be said 
that the amount of food taken at each feeding at first 
should be that indicated in the table on stomach ca- 
pacity (Figure 19, page 48). 

Test for quality of breast milk. — The determination 
of the quality of breast milk is somewhat more diffi- 
cult and in order that the result may be at all accu- 
rate the specimens for examination must be very 
carefully taken, so as to represent good mixed breast 
milk and not the first milk or the last milk from the 
breast, for it is true in breast milk as in cow's milk 
that the first milk is very poor in fat, while the last 
milk is comparatively rich. It has been suggested 
that all the milk from the breasts should be taken, 
but this is practically impossible with a breast pump 
or massage and it is quite sufficient to obtain a mix- 
ture of the first and last milk. But it is important 
that the samples should be taken from each breast, 
as the breasts may differ both in the amount and the 
quality of milk secreted. 

Method of obtaining specimens for examination. — 
The mother should be provided with four one-ounce 
bottles with labels. She first procures a little more 
than one-half ounce of milk from the left breast be- 
fore nursing and puts it into a bottle labeled L. 1. 



FEEDING DURING THE FIRST YEAR 123 

This sample taken before nursing is fairly easily 
obtained. The child is then nursed at the left breast 
for not more than three or five minutes, when the 
breast pump or massage is again applied and an at- 
tempt made to procure another sample in excess of a 
half ounce, which is labeled L. 2. In the same way a 
specimen of the first milk from the right breast is 
obtained and marked R. 1, and another obtained after 
three or five minutes nursing is marked R. 2. 

If at the first attempt the full amount is not 
obtained, the remainder may be procured in the same 
way at the next regular time for the use of that 
breast. In this way the samples before and after 
nursing each breast can usually be obtained during 
one day, so that they may be sent in the afternoon to 
the physician for examination. 

Normal breast milk analyses. — An anlysis of nor- 
mal breast milk will show from 3 to 4 per cent, fat ; 
about 6 or 7 per cent, sugar, and 1 or 2 per cent, 
protein. (Figure 24, page 71.) The fat is in emul- 
sion and seen under the microscope consists of 
small globules suspended in a watery solution. The 
sugar is lactose or sugar of milk which is in solu- 
tion, while the protein consists mostly of lactal- 
bumin, which is in solution and forms a fine curd and 
comprises two-thirds of the protein of breast milk, 
one-third being caseinogen, which forms in much 
tougher curds and corresponds to the protein which 
predominates in cow's milk. In addition, breast 
milk contains from .18 per cent, to .25 per cent, of 



124 



ELEMENTS OF PEDIATRICS 



salts of various sort, but with these we do not usually 
concern ourselves in our endeavours to ascertain the 
quality of breast milk. 

The components of breast milk vary somewhat in 
the amount present, the sugars being fairly constant, 
the protein somewhat variable, while the fats vary 
in amount still more. 

There are three methods of obtaining information 
as to the chemical constituents of milk, varying in 
accuracy in the order in which they are taken up. 

Holt's test. — Of the methods 
of analysing breast milk the 
least reliable, but the one gen- 
erally used for ordinary clin- 
ical purposes because it is 
readily made, is the method 
devised by Dr. Holt. This 
method is based on the fact 
that since fats make milk 
light, while the sugar and pro- 
tein make it heavy, if one can 
learn the amount of fat pres- 
ent in any specimen and also 
learn its specific gravity he 
can then estimate the total 
solids, and variation in the 
other solids usually means 
variation in protein. 

Dr. Holt's apparatus (Fig- 
ure 34) consists of a very 
small lactometer and glass, 




H-IO 



s— $o 



Lactometer. 



Cream 
Gauge. 



FIGURE 34. 



Apparatus for Examina- 
tion of Breast Milk. 
Dr. Holt. 



FEEDING DURING THE FIRST YEAR 125 

which will take the specific gravity of one-half ounce 
of milk ; and a creamometer, which can be used with 
the same or smaller amounts. To make the test, the 
milk is first put into the lactometer glass, the spe- 
cific gravity taken and recorded and then poured 
into the creamometer, where it is allowed to stand at 
room temperature for from eighteen to twenty-four 
hours, when the amount of cream present may be 
read off. Such a test should be made of all four spe- 
cimens, then by adding together the results of the 
examination of the first and last milk of each breast 
and dividing by two a mixed milk result is obtained 
as well as some information as to what the child re- 
ceives at both ends of nursing. 

An interpretation of the results thus obtained is 
aided by a table which is prepared by Dr. Holt and 
which is supplied with this apparatus, and from this 
we learn that a sample containing 7 per cent, cream 
and having a specific gravity of 1030 may be con- 
sidered normal. 

If the specific gravity is low and the fat high, we 
assume that the milk is a rich milk with a normal 
amount of protein. If the specific gravity is high 
and the fat is high we know that both protein and 
fats are in excess. If the specific gravity is high and 
the fat is low we have a milk that is poor in fat and 
perhaps normal in protein, whereas if we have a 
specific gravit}^ that is low and the fat is low, it is 
evident that the milk is poor in both protein and fat. 
Difficulty in using this apparatus sometimes exists 



126 ELEMENTS OF PEDIATRICS 

where there is an excess of fats, as fats may not 
under these circumstances readily rise. 

Babcock test. — A method of obtaining a more ac- 
curate fat test is by the use of a Babcock centrifuge, 
and this is the method the writer uses. For this 
purpose an electric or hand centrifuge can be pur- 
chased with the necessary glassware from dairy sup- 
ply houses. 

To make the test, about 17.6 C.C. (a little more 
than half an ounce) of milk are drawn into a pipette 
graduated for this purpose and then allowed to pass 
into a long-necked flask made for use with this ap- 
paratus. Then 17.5 C.C. of sulphuric acid, having a 
specific gravity of 182 is poured into a glass graduate 
and this in turn is emptied into the flask, care being 
taken that the flask is held in an oblique position, so 
that when the acid passes into the flask the air passes 
out above the stream. The flask is now agitated, so 
that the acid and milk may become thoroughly mixed 
and the flask for the test is then placed in the cen- 
trifuge and turned at a speed indicated on it, for 
five minutes. This speed being intended to produce 
nine hundred revolutions a minute. The flask is 
then taken out and filled to the bottom of the neck 
with hot water, replaced and turned for two minutes, 
after which hot water is again added, so as to bring 
the level of the fluid well up into the graduated neck, 
and replaced for a final two minutes' centrifugation, 
after which the fat can be readily read off as a trans- 
parent layer in the neck of the flask. This test 
should be made in a warm place and the water added 



FEEDING DURING THE FIRST YEAR 127 

should be fairly hot, in order that an accurate deter- 
mination can be made. 

Chemical analysis. — This determination of fat 
together with the specific gravity allows a moder- 
ately accurate estimation of the solids, but in cases 
where the greatest accuracy is desired a thorough 
chemical analysis may be preferred. This, however, 
is a matter of considerably more expense and delay 
than the simpler methods that have here been de- 
scribed. 

Value of analysis. — Although by such analyses we 
may obtain data as to the condition of the milk at the 
time the specimen was secured, it cannot be assumed 
that a similar result of analysis could be obtained a 
day or a week later. Nervous shock, worry or even 
attacks of indigestion or physical fatigue, may cause 
rapid changes in the chemical composition of breast 
milk. 

Inadequate nursing. — The symptoms which are 
produced by inadequate feeding should be clearly in 
the mind of every practitioner, for babies are fre- 
quently seen who, while breast fed, have been allowed 
to go from three to nine months with no appreciation 
on the part of the parent and physician that the feed- 
ings were inadequate. The most important evidence 
of inadequate feeding is not necessarily a loss in 
weight, but a failure to gain in weight. Any healthy 
child who, during the first year, fails to gain for 
several successive weeks, is not being satisfactorily 
fed, for a normal child will show an almost constant 
weekly gain throughout the first year. Restlessness 



128 ELEMENTS OF PEDIATRICS 

is present in some of the underfed children, although 
many of them neither cry on being taken from the 
breast nor show any eagerness for more food. The 
intestines often show disturbances, the most common 
of which is constipation, while other children, in 
whom the starvation is more severe, have loose, 
green, undigested stools each day. A noticeable fea- 
ture of these stools is that they contain very little 
fecal matter. 

A symptom of starvation which is not uncommon 
during the first week of life is a rise of temperature, 
sometimes to 102 or 104 degrees Fahrenheit. This 
temperature rapidly becomes normal on the adminis- 
tration of sufficient food. 

Bacteriology of mother's milk. — Considerable mis- 
apprehension has arisen concerning the bacteriology 
of mother's milk, it having been assumed that in- 
fants in nursing obtain a sterile food, and this has 
been used as an argument for the sterilisation of milk 
for infant feeding. This, however, is far from true, 
careful investigation of breast milk by different 
observers having shown that not more than one- 
eighth or one-ninth of the women's breasts examined 
contained sterile milk ; that usually some one of the 
pyogenic bacteria were present; the staphylococcus 
pyogenes albus having been the most frequent, while 
the staphylococcus pyogenes aureus and the strepto- 
coccus were frequently present. 

Moreover, if the milk in the breasts were sterile it 
is evident that babies in many households where 
cleanliness is not emphasised, must obtain many bac- 



FEEDING DURING THE FIRST YEAR 129 

teria from a nipple that is depressed between folds 
of skin, except when nsed by the baby for feeding; 
that in snch cases the baby really cleanses the nipple 
with its lips and tongue at the time of nursing. 

Care of nursing mother. — Before considering the 
treatment of any abnormality of the milk, it may be 
well to lay down the rules that should be followed in 
order that nursing may be successfully carried on. 

The nursing mother should have a full nutritious 
diet, taking three regular meals, with sometimes an 
extra feeding at night, but the method of over-feed- 
ing a nursing woman and thus giving rise often to a 
disordered digestion should be avoided. She should 
take no indigestible food, but may take an ordinary 
mixed diet, being careful only that it contains suffi- 
cient food value and plenty of fluid. She should be 
protected as far as possible from sources of worry, 
as nervous shock to the mother may materially 
diminish and injure the quality of the breast milk, 
while prolonged nervous irritation may put an end 
to lactation. 

What is true of nervous fatigue is also true of phy- 
sical fatigue, and it is not uncommon to see a woman, 
who, while confined to bed, has sufficient milk to 
nurse her baby, but is unable to nurse the child after 
getting up. Thus a nursing woman should be free 
from nervous worry, and physical exertion should be 
increased only so long as there is no deterioration in 
the milk. After lactation is well established, it is 
perfectly feasible for many women to take very con- 
siderable exercise, and I have known women to play 



130 ELEMENTS OF PEDIATRICS 

tennis all summer while successfully nursing a baby. 

It is during the first month or two of lactation that 
these precautions must be particularly observed. 

In the beginning of lactation a diminution in the 
amount of milk can often be overcome by increased 
rest and increased fluids, particularly by drinking 
more milk, and by nursing both breasts at each feed- 
ing; while the administration of two drachms of a 
thick malt extract after each meal, with massage of 
the breasts for five or ten minutes night and morn- 
ing will, in most cases, give satisfactory results. It 
must, however, be remembered that in some cases 
these results are obtained very slowly and so long as 
some increase in the milk is being obtained all these 
measures should be persisted in. 

If it is found, on chemical analysis, that the quality 
of the milk is disturbed, there may be other special 
indications for its treatment. Although the methods 
already advocated for increasing the quantity are 
also effective in increasing the quality of the milk, 
and while certain methods are advocated for chang- 
ing the chemical composition as hereinafter indicated, 
success with these special methods is not to be de- 
pended upon. It may also be said that when breast 
milk shows marked deviation from normal, particu- 
larly when having both very low protein and fats, 
the chances of obtaining normal milk from the 
breasts are not good. 

It should, however, be remembered that no matter 
what abnormality of the milk may exist, if such as 
the mother is able to supply seems to agree with the 



FEEDING DURING THE FIRST YEAR 131 

baby, every effort should be made to keep it, and in 
addition accessory feedings of artificial food may be 
given to supply the baby with sufficient nourishment 
to cause an increase in weight. 

Some modification of the character of breast milk 
may be occasionally accomplished by treatment of 
the mother. 

Too abundant breast milk soon adapts itself to the 
requirements of the baby while a deficient amount or 
a milk of moderately poor character may be im- 
proved often by the administration of a thick malt 
extract and massage of the breast, as well as by a 
strict regime for the mother. The quiet environ- 
ment of a country home will often aid. Milk of a 
low specific gravity, 1025, and with only 1 or 1% 
per cent, fat can rarely be raised to a satisfactory 
standard. 

A very frequent abnormality in breast milk among 
the better classes in New York is a condition of high 
protein and low fat; this is usually found in rather 
active, nervous women and is frequently accom- 
panied by severe colic on the part of the baby. This 
condition may often be modified as the lactation goes 
on, if the mother can be kept free from excitement, 
worry and fatigue. 

While it is difficult to make poor breast milk good, 
it is perfectly feasible on ascertaining the deficien- 
cies of the breast milk, to add supplementary feed- 
ings, and thus provide the child with both a normal 
formula and with breast milk. (See Mixed Feeding, 
p. 141.) 



132 ELEMENTS OF PEDIATEICS 

An ounce or two of breast milk at each feeding is 
of advantage during the first five months, although 
this may seem an insignificant part of the total feed- 
ing. 

It is not uncommon to see babies who during nurs- 
ing continue to gain although having stools that 
always contain curds and mucus, and when put on 
artificial food their stools become normal, but they 
may not gain in weight. Therefore, poor stools in 
themselves in nursing babies are not an indication 
for weaning. Finally, do not abandon the breasts, 
as long as they give any material assistance. 

Methods of feeding. — Previous to feeding, the nip- 
ple should be well washed with a solution of boracic 
acid, but the mouth of the baby should not be washed. 
The washing of the baby's mouth often results in a 
contamination and in the removal of epithelium and 
the production of superficial ulcers. Nothing should 
be put in the baby's mouth that is not absolutely clean. 
The washing of the mouth is unnecessary and dan- 
gerous. 

The baby should be held at the breast in an ap- 
proximately horizontal position with the head sup- 
ported. If it takes the milk very fast and chokes, it 
should be taken occasionally from the breast for an 
instant and then put back. The child may remain 
at the breast until it is satisfied, if it is not vomiting 
and is gaining well. If, however, it vomits after 
feeding, the amount taken ought to be determined 
and the duration of nursing cut down until such 
vomiting ceases. 



FEEDING DURING THE FIRST YEAR 133 

No normal baby should be kept at the breast after 
it becomes sleepy, this condition being an indication 
that the baby has had sufficient food. The child 
should then be taken from the breast and not fed 
again until the next regular interval. 

After each feeding the baby should be held in an 
upright position and patted on the back until the air 
it has swallowed during nursing has been expelled 
and when put to bed, if subject to colic, should be laid 
on the stomach or right side, for in such position the 
opening of the oesophagus into the stomach is above 
the level of the stomach contents. 






CHAPTER XII 

WEANING 

Weaning, the process of taking a child from breast 
milk and putting it entirely on an artificial food, 
should not be undertaken, if avoidable, before the 
third month and should not often be delayed after 
the eighth or ninth month. Within these limits, the 
longer it is delayed the better, even if the amount of 
breast milk is but a small proportion of the total 
amount of food taken. In the case of very poor per- 
sons a longer period of nursing may be deemed ad- 
visable on account of the difficulty in providing clean, 
fresh, cow's milk, and in securing its proper modifi- 
cation. 

Indications. — The indications for weaning may 
exist in the child or in the mother. 

The child. — First — A child who has nursed eight 
months and ceased to gain at a satisfactory rate, that 
is, three or four ounces a week, should usually be 
weaned. 

Second — A child who in the early months has con- 
tinual colic, with bad stools and failure to gain, and 
who is found on trial to do much better on artificial 
food, should be put on mixed feeding, or if the 
symptoms persist even with a small amount of 
breast milk, should be weaned. 

134 



WEANING 135 

Third — Occasionally a child apparently doing well 
on breast milk will suddenly refuse the breast, but 
will take what is offered from the bottle. Such a 
demand for weaning may be imperative. 

The mother.— Indications on the part of the 
mother are more numerous. 

First — Occasionally the mother is rendered most 
uncomfortable by cracked nipples and dreads nurs- 
ing on account of pain accompanying it. In this 
case proper applications to the nipples and the use 
of a nipple shield should relieve the condition, which 
is rarely an indication for weaning. 

Second — Menstruation of the mother is never an 
indication for weaning. The baby may not do quite 
as well while the mother is menstruating, but will do 
well again during the interval between menstrua- 
tion. 

Third — Pregnancy is always an indication for 
prompt weaning. No mother should be required 
to feed a baby at the breast while nourishing a 
foetus. 

Fourth — Acute disease on the part of the mother, 
if of short duration, is rarely an indication for wean- 
ing, although a lessened activity of the breasts may 
require accessory feeding. The child should, how- 
ever, be protected as far as possible from acquiring 
the disease from which the mother is suffering. If it 
involves the upper air passages of the mother a towel 
should be thrown over the head of the child during 
nursing. 

Fifth — Septic complications after childbirth, if 



136 ELEMENTS OF PEDIATEICS 

long continued, usually compel weaning by loss of 
activity of the breasts. 

Sixth — Syphilis on the part of the mother need not 
contra-indicate nursing, unless the baby has a nega- 
tive Wassermann reaction. 

Seventh — While a robust mother with an inactive 
tuberculous lesion might be allowed to nurse her 
baby, no mother with an active tuberculous process 
should nurse, both on account of the danger to the 
baby, for babies have very slight resistance to tuber- 
culous infection, and in them tuberculosis is usually 
an acute, rapidly spreading, general disease, and also 
on account of the fact that tuberculous mothers are 
very liable to a rapid spread of the disease in the 
period of relaxation following pregnancy. 

The method. — In beginning to wean a child first 
introduce one bottle of a normal feeding (p. 178) 
suitable usually for a somewhat younger and smaller 
child and watch the effect, whether it satisfies the 
child and whether its administration is followed by 
any evidence of disturbance of the stomach or intes- 
tines of the child. This will aid in forming a judg- 
ment as to whether more or less food, or a weaker or 
stronger formula should be used. When the bottle 
is suited to the needs and digestive capacity of the 
child, a second should be introduced and every two or 
three days another, until the mother is nursing the 
baby at both breasts every twelve hours, the remain- 
ing feedings being from bottles. These two nurs- 
ings a day should be continued until there is little 
filling of the breasts and the baby does not get more 



WEANING 137 

than two or three ounces from the breasts. Then 
the mother may be given a very dry diet and have 
a tight breast binder put on for two or three days, 
during which period the bowels should be kept loose 
by saline laxatives. One nursing a day should never 
be used. 



CHAPTEB XIII 

WET NUESING 

Although the milk of a wet nurse is in some re- 
spects the best substitute for mother's milk, for 
many reasons wet nurses are being less and less used 
as our resources for artificial feeding increase, and 
the wet nurse now is ordinarily used only for those 
babies so seriously handicapped by prematurity, con- 
genital defect, or early neglect, as to be extraor- 
dinarily difficult to feed artificially. In private prac- 
tice, where the babies are carefully controlled from 
birth, wet nurses are rarely seen. On the contrary, 
in our institutions, where the babies have suffered 
from early neglect, bad heredity and frequently from 
specific infection, wet nurses are most necessary, in 
order to reduce the high mortality. 

The objections to wet nurses may be briefly sum- 
marised when we state that they are difficult to find, 
they are usually unmarried, and unmarried mothers 
are women of a low grade of intelligence, and are 
undesirable in a household; that it is impossible 
to demonstrate absolutely that they have no dan- 
gerous disease; that they usually have to be taken 
from their own infant, of whom they are fond, and 
their unsatisfied desire to see their infant after being 
isolated in a household will often react badly on their 

138 



WET NURSING 139 

milk supply. Accustomed to poor food and hard 
work, the richer food and comparative freedom from 
labour is likely to result in digestive derangement 
which interferes with lactation. Often they cannot 
be trusted to care for the baby on account of igno- 
rance or unreliability. 

In selecting a wet nurse it is best always to obtain 
her from an obstetrical institution, where the woman 
has been under observation for several days, or from 
a milk depot registry, but, failing in this, an agent 
must be employed to look one up in the tenements. 
The wet nurse should preferably be young and one 
whose baby is from two to three months old, as her 
lactation is then well established and the prospect of 
her own baby doing well on artificial food is better 
the older it is. There is no advantage in obtaining 
a woman whose baby is the same age as the baby to 
be nursed. 

The wet nurse should be thoroughly examined for 
evidence of tuberculosis, syphilis, gonorrhea or other 
diseases that may be transmitted, and her milk 
should be examined as to both its quantity and 
quality. Abnormalities in the quantity and quality 
of the milk in an otherwise promising woman should 
not bear too much weight, as the nervous strain of 
this examination may cause temporary irregularities 
in the milk. If the woman's baby appears to be 
healthy and doing well, such irregularities need not 
result in the immediate rejection of the woman. 

It is most important that the wet nurse's baby 
should also be placed under proper control, for 



140 ELEMENTS OF PEDIATEICS 

unless this is done the mother sends the baby to some 
baby farm, where the child is likely to obtain a 
gonorrheal infection and to be badly fed. These 
wet nurses' babies should be placed in proper insti- 
tutions for their care. 

The wet nurse's diet should be regulated so as to 
be simple and nourishing and in the larger establish- 
ments one has to take care that sufficient milk is sup- 
plied to the wet nurse and not too much rich food, 
while some work that she can do must be found for 
her. 

It is also desirable that the woman should take a 
bath as soon as she enters the house and that an 
entire set of clean clothes be furnished, her. 



CHAPTER XIV 

MIXED FEEDING 

So-called mixed feeding, the use of some breast 
milk and as much artificial food as is necessary to 
meet the needs of the child, is one of the most satis- 
factory methods of feeding. The first mixed feeding 
resorted to is usually an emergency bottle to allow 
the mother more freedom or to gradually accustom 
the baby to digest cow's milk. This should only be 
used when the supply of breast milk is well estab- 
lished, for frequent nursing stimulates the secretion 
of the breasts. 

Emergency bottles. — An occasional emergency 
bottle is most easily prepared from a dried or malted 
milk, and should contain an amount appropriate to 
the age and general condition of the child, but when 
the emergency bottle becomes a daily feeding, in 
order to give the mother more freedom, and espe- 
cially if weaning is contemplated, it should be pre- 
pared from a modification of cow's milk suitable to 
the child, always beginning with a low formula, which 
can be increased gradually. 

Accessory feedings. — The second kind of mixed 
feeding is that in which a bottle is fed with each 
nursing. This is used most often when the mother is 
nursing, but when her milk is either inadequate in 

141 



142 ELEMENTS OF PEDIATEICS 

quantity or quality, so that the child does not gain on 
her milk alone. 

Accessory feedings may be given before or after 
nursing. If used to replace a deficiency in the 
quality of breast milk or to dilute a too rich breast 
milk it is better to feed before nursing. Also, if the 
breast is well taken and the bottle often rejected, 
the bottle should be given before the breast milk. 
When, however, one is correcting a deficiency in the 
amount of breast milk and the bottle is taken well, 
it should be given last, so that there may be an oppor- 
tunity to weigh the baby before and after nursing, 
and thus ascertain just how much of the bottle may 
be fed. 

The amount of breast milk secreted usually varies 
at different times of day, so that ordinarily weighing, 
for two or three days, before and after the early 
morning, noon and evening feeding will indicate the 
amount of accessory artificial food needed at each 
feeding. In inadequate lactation, much more milk is 
usually secreted at the morning feeding than either 
at noon or at night. 

If the breast milk is too rich, thus causing diges- 
tive derangements in the child, one-half to one ounce 
of barley water may be given to the child before 
each nursing, sometimes with great benefit. 

If the quantity of the mother's milk is too much, it 
may be reduced by shortening the duration of nurs- 
ing until the amount taken by the child corresponds 
to the child's gastric capacity. 

When the breast milk contains too little fat, the 



MIXED FEEDING 143 

feeding of a pasteurised cream before nursing will 
often determine a gain in a child who is keeping 
a stationary weight. For this purpose one-half 
drachm or a drachm of the top ounce of a bottle of 
milk may be given to the child before nursing, or 
enough to supply a normal fat content. On the 
other hand, if the protein is low, a dry milk or a 
malted milk dissolved in one-half ounce of barley 
water may be given to the child before each feeding. 

If the analysis shows the milk low, both in fat and 
protein but sufficient in amount, then the cream and 
dry milk dissolved in one-half ounce of barley water, 
while supplying the solids of the milk, will not dis- 
place the watery elements and the ferments they con- 
tain. 

If the breast milk is deficient in amount, a modified 
milk feeding after nursing is best, used with the per- 
centage of fat, sugar and protein in it, adjusted in 
accordance with the richness of the breast milk the 
child receives. 

Mixed feeding of this sort has received much less 
attention than it deserves and when properly carried 
out is infinitely better than weaning, and is often 
much more satisfactory than breast feeding alone, 
for we can, while still using breast milk, arrange the 
formula of the food to best suit the need of the child. 

In case of illness, worry or extreme fatigue on the 
part of the mother, a temporary diminution in the 
amount of breast milk will have to be corrected by 
similar accessory feedings until a normal activity of 
the breasts is restored. 



CHAPTER XV 

ARTIFICIAL FEEDING 

The successful artificial feeding of any large 
group of babies requires special skill, many re- 
sources, and large experience, and it is probably on 
account of the poor success of general practitioners 
in the feeding of babies, that the specialty of pedia- 
trics has been as fully developed as it is, and the wet 
nurse has become a rare resource. 

Many babies digest easily almost any kind of arti- 
ficial food on which they are fed, if they have had a 
fair start on breast milk, and some even at first do 
well on artificial food, others are difficult to make 
gain on artificial food, but by the use of good judg- 
ment in changing from one formula to another almost 
all babies can, in a reasonable time, be fitted to an 
artificial food on which they will thrive. 

The subject of infant feeding is, therefore, perhaps 
the most important of all subjects in pediatrics. 

Cow's milk. — In seeking a substitute for breast 
milk, one naturally turns to cow's milk as the avail- 
able commercial product, and the milk of other ani- 
mals has not been shown to have sufficient advantage 
over cow's milk to replace it. The author has re- 
cently had an opportunity of comparing the results 
of feeding goat's milk and cow's milk, and is inclined 

144 



AETIFICIAL FEEDING 145 

to think that in some cases there is an advantage in 
feeding goat's milk. 

To use cow's milk successfully, we should first ob- 
tain clean cow's milk, and should then modify it to 
suit the digestive capacity of the baby. We should 
render it as free from bacteria as possible, and 
should feed it in proper amount and at regular in- 
tervals. 

The obtaining of clean cow's milk is not difficult in 
large communities where a supply of good certified 
milk is at hand, but where this is not the case an 
effort must be made to create such a supply. 

Certified milk. — Certified milk is milk produced 
under a plan devised by the late Dr. Henry L. Coit, 
of Newark, New Jersey, who felt the need in his 
pediatric practice of a milk supply subject to bac- 
teriological and chemical tests, and produced on a 
farm where he could control the conditions. This 
plan involved a contract between a commission of 
physicians, who served without compensation, and a 
dairyman, who was under bond to satisfy the reason- 
able desires of the commission for the production of 
a clean, safe milk, he to receive the support of the 
members of the commission and to have the privilege 
of using the word certified which carried with it an 
opportunity for an increased price for his milk. 

Dr. Coit's original commission employed, at the 
expense of the dairyman, a chemist, who analysed 
the milk at regular intervals; a bacteriologist, who 
also acted as a hygienist, who examined the milk for 
bacteria and then devised methods for improving 



146 ELEMENTS OF PEDIATEICS 

the handling of the milk at the farm in order to 
reduce the contamination ; a veterinary who was re- 
sponsible for the good health of the cows and for 
the elimination of cows that were sick or a danger 
to the milk supply ; and a physician who was respon- 
sible for the health of the employes and the isolation 
of the sick. 

This scheme has been very successful and has 
really put the production of clean milk in the hands 
of the physicians who are using it in their practice, 
and it has also taught these physicians, as well as 
Boards of Health and the public, the essential details 
in the production of clean milk. It has also resulted 
in the application of scientific methods to dairy hy- 
giene. This plan of Dr. Coit's has been adopted all 
over this country, so that many of the large cities 
now have supplies of certified milk. 

The essentials for the production of clean, health- 
ful milk may be briefly summarised as follows : 

The cows should be tuberculin tested. The sta- 
bles must be well lighted, well ventilated, and kept 
absolutely clean. Cement floors are essential. The 
udders of the cows should be clipped as well as the 
left side above the udder, in order to remove the 
long hairs which retain dirt. The hair on the cow's 
tail should be kept closely cut. The cows should be 
groomed before milking and before they are 
groomed a chain should be fastened across the yoke 
under the neck, to prevent them from lying down 
after grooming and before milking. The udder, 
flank and tail of the cow should be washed, rinsed 



ARTIFICIAL FEEDING 147 

and dried before milking. The milking should be 
done by a man in a clean white suit, and cap, with 
hands that have been washed clean and dried, and 
kept dry during milking. The milk should be re- 
ceived into a pail with a hood to protect it from the 
perpendicular droppings of dust and bacteria from 
the belly and udder of the cow, and should be 
cooled as soon after milking as possible and kept 
below fifty degrees F. until it is delivered to the con- 
sumer. All the receptacles into which the milk is 
drawn or placed should be sterilised and the bottles 
in which the milk is sold should be carefully cooled 
after sterilisation, so that they will have a temper- 
ature of fifty degrees when the milk is put into 
them. 

While ordinary milk often contains a million 
bacteria to a drop, milk produced in the above man- 
ner usually contains less than 100 bacteria per drop, 
sometimes none. 

Contamination of milk with bacteria. — The writer 
has demonstrated by bacteriological experiments 
that the great contamination of milk with bacteria 
is ordinarily from the perpendicular droppings 
of dirt loaded with bacteria from the hair covered 
udder and belly of the cow, which is agitated dur- 
ing milking. Thus by exposing three sterile petrie 
plates containing sterile neutral agar, two minutes 
each, out of doors, in the barn, and under the udder 
of the cow during milking, he found on the plate ex- 
posed outdoors only six colonies of bacteria, in the 
barn, something over one hundred, and under the 



148 



ELEMENTS OF PEDIATRICS 



cow over two thousand. (Figure 35.) This experi- 
ment he has repeated several times, with similar re- 
sults. 

To avoid this contamination, the clipping of the 
cow, the washing of the belly and udder, the hooded 
pail and quiet milking are necessary. 

A less extensive but more dangerous source of 
contamination is from the hands of the milkmen, 




FIGURE 35. 

Plates Showing Contamination to Which 
Milk is Exposed feom the Dust of the 
Barn and the Droppings from the Belly 
and Udder of the Cow. 

A. Petrie plate exposed two minutes out of 

doors. Contains 6 colonies. 

B. Petrie plate exposed two minutes in barn. 

Contains 111 colonies. 

C. Petrie plate exposed two minutes under cow 

being milked. Contains 1800 colonies. 



particularly if their hands or fingers have come in 
contact with bacteria which carry disease in man, 
such as typhoid, diphtheria, etc. It is, therefore, 
necessary that the milkers should wash their hands 
before and after each milking, so as to keep them 
clean, that the barns should be equipped with wash- 



AKTIFICIAL FEEDING 149 

ing facilities, soap, water, nail brushes and towels, 
and that the milkers should be instructed to keep 
their hands dry during milking. Moreover, it is 
necessary that the milkers should milk quietly with- 
out jerking the teats, for experiments by the author 
have shown that milkers who jerk the teats cause 
about ten times as much contamination of the milk 
with bacteria as those that simply squeeze the teats. 

A third source of contamination is dirty water, 
which may be used for washing the utensils or for 
diluting the milk. A dirty towel used for drying 
milk utensils which had previously been used in the 
care of a typhoid fever patient caused one milk epi- 
demic of typhoid fever. Another source of con- 
tamination of milk is the presence of bacteria in the 
udcler of the cow, but this is one easily avoided by 
intelligent supervision, for unless the cow has evi- 
dent disease of the udder or leaky teats there is 
rarely any extensive growth of bacteria in the udder. 
When there is much udder contamination it is 
usually most marked in the lower segment, so that 
the greatest contamination is in the first milk, but 
some contamination persists even to the last of the 
milking. A number of milk epidemics have been 
caused by married employes contaminating the milk 
with germs of disease present in their families. On 
some farms, therefore, the employes are all single 
men, who live on the farm and are under medical 
supervision and who are not allowed to handle the 
milk unless they are well. 

In order to eliminate the danger of typhoid ba- 



150 ELEMENTS OF PEDIATRICS 

cilli being conveyed to the milk from the milkers 
or handlers of the milk, all the employes of the farms 
certified by the Milk Commission of the Connty of 
New York are tested by means of the Widal reaction. 
Those men having a negative test receive a certificate 
to that effect. 'No man who has had typhoid fever 
or who has a positive Widal test is allowed to work 
on their certified farms ; and no man who has worked 
on one of their certified farms and has not a certifi- 
cate of a negative Widal may be employed on an- 
other of their certified farms. 

The elimination of all tuberculosis in the herds on 
certified farms has been a difficult matter and 
usually on re-testing one of these herds a certain 
number of reactors are found. At the present time, 
therefore, it is being urged on the farmers that they 
keep their herds free from tuberculosis by frequent 
tuberculin tests, and by raising their own calves, 
thus eliminating the danger from newly purchased 
cows. Cows bought for certified farms are all sub- 
jected to the tuberculin test, but if they have re- 
cently been injected, the test will be negative and 
only a subsequent test will reveal the tuberculous in- 
fection of the animal. The frequency of the re- 
testing of these herds should depend on the number 
of reactors found, the interval should not be longer 
than one year and usually not more frequent than 
once in six months. 

Now, having resorted to milk that has been pro- 
tected by all these precautions, it is still advisable 
to pasteurise it, for while these precautions protect 



ARTIFICIAL FEEDING 151 

the milk to a certain extent, they cannot absolutely 
secure it against the conveyance of disease. 

Composition of cow's milk. — Cow's milk contains, 
as seen by the table (Figure 36), about 4 per cent. 

FIGURE 36. 

ANALYSIS OF COWS' MILK 

Fat 4. 

Sugar 4.30 

Protein 4. 

Salts 70 

Water 87. 

100.00 

each of fat, sugar, and protein, and .7 of 1 per cent, 
of salts, as against 3 to 4 per cent, fat, 6 per cent, 
sugar, and 1 to 2 per cent, protein, and one-fourth 
of 1 per cent, of salts in woman's milk. It is thus 
evident that we have a very much larger amount of 
protein in cow's milk, which will need diluting in 
order to allow this milk to compare at all with 
mother's milk. 

The fat of cow's milk, which is about equal to 
the protein in amount, is the same sort of fat as that 
in mother's milk, and is in emulsion. 

The salts in cow's milk exist in about three times 
the amount they do in breast milk and differ some- 
what in the proportion of each, as seen by Figure 
37, which is made up from averages of a number of 
the more recent chemical analyses of the salts in 
human and cow's milk. It is evident that potas- 



152 ELEMENTS OF PEDIATRICS 

sium, sodium and chlorine are present in large pro- 
portion in human milk, while in cow's milk the pro- 
portion of lime and phosphorus is greater. Iron is 
present in about seven times as great a quantity in 
human milk as in cow 's milk. 

The richer appearance of cow's milk, as compared 
with mother's milk, is due to an increase in the 
opacity caused by the combination of calcium phos- 

F1GURE 37. 
MINERAL MATTER IN MILK 

Human milk Cow's milk 

Potassium oxide 24. 21. 

Sodium oxide 16. 11. 

Calcium oxide 17. 21. 

Magnesium oxide 3.25 2.9 

Ferric oxide 75 .1 

Phosphorus Pentoxide 19. 28. 

Chlorine 20. 16. 



100.00 100.00 

phate with casein, calcium phosphate being much 
more abundant in cow's milk than in mother's milk. 

The sugar of cow's milk is lactose, as in human 
milk, but is present in about one-third less amount. 

The protein of cow's milk, as we have already 
seen, is present in larger proportion than in human 
milk, and is also of a character more difficult of 
digestion, for while in breast milk we have both lact- 
albumin and caseinogen, the proportion of each in 
cow's milk is entirely different. Lactalbumin which 
is in solution and forms fine curds, comprises two- 



ARTIFICIAL FEEDING 153 

thirds of the protein of breast milk and only one- 
sixth the protein of cow's milk, so that the remaining 
five-sixths of caseinogen makes the curds of cow's 
milk much larger and tougher and more difficult of 
digestion. Fortunately, however, we are able to 
split the protein of cow's milk and feed whey, which 
is a lactalbumin milk. 

The composition of cow's milk, as shown in the 
table, represents approximately the composition of 
a mixed certified cow's milk. Ordinary cow's milk 
in New York contains little more than 3 per cent, 
fat, which is required by the regulations of the 
Health Department. Certified milk contains 4 per 
cent. fat. The milk of special cows or special herds 
will vary materially, thus Jersey cows may give 5% 
or 6 per cent, fat, while Holsteins may give less than 
3 per cent. The sugar and protein in these milks 
remain much the same. It is, therefore, necessary 
before modifying milk for infant feeding to know 
not only the conditions at the dairy where the milk 
is produced, but the fat content of the milk as well. 



CHAPTER XVI 

THE MODIFICATION OF MILK 

The modification of milk for infant feeding has 
for years been used in different countries, because 
undiluted cow's milk has not been successful clini- 
cally in feeding infants during the first months of 
life. The dilutions of milk with water or barley 
water to one-fourth, one-third, or one-half have for 
many years been used. In this country a much 
more accurate dilution, with an attempt to simu- 
late mother's milk, has been in vogue for the past 
twenty-five years, as urged by Dr. Eotch. 

The same reasonable method had been urged fifty 
years before by Dr. Cummings, of Williamstown, 
Massachusetts, who wrote a book on his method, 
which was entirely forgotten before Dr. Botch's 
work. 

Dr. Eotch urged that, as breast milk contained 
two or three times as much fat as protein and cow's 
milk equal parts fat and protein, an infant should 
not be fed on diluted cow's milk, but on a diluted 
cream mixture, in which the proportion of fat to 
protein would be the same as mother's milk, and that 
as there was no cereal diluent in the breast milk, 
plain water should be used for diluting cow's milk, 
and sugar of milk should be added to cow's milk 

154 



THE MODIFICATION OF MILK 155 

to raise the percentage of sugar of the milk to that 
which exists in mother's milk. He also stated that 
fractional differences in composition should be used 
in making changes from one formula to another, and 
he was instrumental in establishing laboratories for 
the accurate modification of milk. A great deal 
that Dr. Rotch taught has been so modified as to 
have little application at present. The most valu- 
able of all the essentials of his teaching was that 
we should, in feeding babies, think in percentages 
of milk and know always just what percentages we 
were feeding, and should bear in mind the compo- 
sition of breast milk. 

It is generally accepted, however, that the fats of 
mother 's milk are too high to use in the modification 
of cow's milk for many babies; that cereals are help- 
ful for digestion, and that the proportion of fat and 
protein in cow's milk is better adapted to some 
babies fed on cow's milk formulae than the propor- 
tion existing in mother's milk. 

In feeding babies artificially it is necessary to fit 
them with a food, and it is customary to start them 
on a formula rather lower than the one we think they 
can take. When they are doing well, we make 
changes about every three days until we reach a 
feeding on which the child will gain satisfactorily — 
the optimum of von Pirquet. If this is a normal 
feeding the baby is left on it as long as it continues 
to thrive. A normal feeding is a feeding of modi- 
fied milk with a proper relationship in the propor- 
tion of fat, sugar and protein. Sometimes it is 



156 ELEMENTS OF PEDIATEICS 

necessary to put a child on feedings containing con- 
siderable malt or other sugar, and low fat, these* 
one tries to reduce gradually, so as to feed what 
might be termed a well-balanced ration. 

Failing to find a food on which a young infant 
will gain a wet nurse should be held in mind as a 
final resort. 

The modification of milk, as usually presented, is 
very complex and often requires algebraic formu- 
lae or tables to be carried or memorised. It is desir- 
able that physicians should be able to modify milk 
without such aid. The following method of milk 
modification requires only such facts as are easily 
memorised, and while not absolutely accurate, is suf- 
ficiently accurate for all practical purposes, and can 
be applied to the preparation of any formula. 

Modification is a dilution of milk or cream, to 
which sugar of milk is usually added. 

Method of modification. — Decide on the formula 
you need and the number of ounces in each feeding. 
Note the relationship of fat to protein in the for- 
mula, and use for dilution a milk or cream with the 
same proportion. Then dilute and add sugar of 
milk. The formula chosen may contain : 

1. Equal amount of fat and protein. 

2. Less fat than protein. 

3. More fat than protein. 

In the formula we use the fat is placed first, then 
the sugar and finally the protein. This rotation is 
always adhered to. 

Suppose we wish to feed daily five bottles of 



THE MODIFICATION OF MILK 157 

eight ounces or forty ounces of a modification con- 
taining 2 per cent, fat, 7 per cent, sugar, and 2 per 
cent, protein. Cow's milk may be considered to con- 
tain 4 per cent, fat, 4 per cent, sugar, and 4 per cent, 
protein, so the relationship between fats and protein 
is the same in cow's milk as in the formula selected. 
The dilution necessary to reduce these materials 
one-half must be an equal part, which may be shown 
mathematically as follows : 

Su- Pro- 
Fat gar tein 
4 — 4 — 4 milk 
— — water 
2) 4 — 4 — 4 
2 — 2 — 2 

Thus of our forty ounces we would use milk one- 
half, twenty ounces, and water twenty ounces, but 
if 5 per cent, of lime water is added, as is customary 
(page 167), that amount must be deducted from the 
amount of plain water used, leaving eighteen ounces 
of water and two ounces of lime water. The sugar 
in the milk after dilution has been reduced to 2 per 
cent., while our formula calls for 7 per cent, or an 
addition of 5 per cent, to the whole forty ounces, and 
5 per cent, of forty ounces is two ounces. Thus our 
complete formula would read : 

Whole milk 20 ounces 

Water 18 ounces 

Lime water 2 ounces 

Sugar of milk 2 ounces 



158 ELEMENTS OF PEDIATEICS 

Another example of a formula for a young baby 
requiring low fats might be, eight bottles of three 
ounces, or twenty-four ounces of a 1-6-1. 

Here again the fat and protein are equal and 
a dilution of whole milk is called for, but it is evi- 
dent that to get 1 per cent, only of fat and protein 
three parts water must be used, thus : 

4 — 4 — 4 milk 

— — 0] 

— — O^water 

— — 0J 
4) 4 — 4 — 4 

1 — 1 — 1 

For twenty-four ounces of this formula we would 
use one-fourth milk or six ounces, and three-fourths 
water or eighteen ounces, less one ounce of lime 
water, thus seventeen ounces of water and one ounce 
of lime water. The sugar must be raised from 1 
per cent, in the dilution to the 6 per cent, called for 
in the formula, requiring the addition of 5 per 
cent, of the twenty-four ounces or 1.2 ounces or one 
ounce, one and one-half drachms. Thus the direc- 
tions would be : 

Milk 6 ounces 

"Water 17 ounces 

Lime water 1 ounce 

Sugar of milk 1 ounce, iy 2 drachms 

To obtain a formula with less fat than protein, a 
skimmed milk must be used. Milk from which grav- 
ity cream has been skimmed usually contains about 



THE MODIFICATION OF MILK 159 

1 per cent, fat or a 1-4-4, while centrifuged milk 
contains so little fat that it may be called a 0-4^4. 

In a difficult case we may want to eliminate the 
fat and use for modification skimmed milk. If we 
wish to make five bottles of six ounces or thirty 
ounces of 0-7-2 formula we would use as in the first 
example one-half milk, but use skimmed instead of 
whole milk, that is to say, of our thirty ounces, fif- 
teen ounces are skim milk and fifteen ounces are 
water, except that one and one-half ounces of the 
water are replaced with lime water, leaving thirteen 
and one-half ounces of water, and 5 per cent, of 
sugar is added, or one and one-half ounces, for we 
find that 5 per cent, of thirty ounces is one and one- 
half ounces, which will give us our formula of 0-7-2, 
that we desired. 

5 bottles of 6 ounces = 30 ounces of — 7 — 2. 
Skim milk — 4 — 4 = 15oz. milk 15 oz. milk 

fLS 1 /^ oz. water 
Water — — = 15 oz. water =■{ IV2 oz - h me 

[ water 

2 )0 — 4 — 4 
— 2 — 2 

5 = iy 2 oz. sugar 1% oz. sugar 

— 7 — 2 

Skim milk 15 oz. 

Water 13V 2 oz. 

Lime water IV2 oz. 

Sugar of milk 1% oz. 

If 1 per cent, protein and no fat is desired, the 
skim milk is diluted with three parts of water or : 



160 ELEMENTS OF PEDIATEICS 

Skim milk — 4 — 4 

CO _ — 

Water^ — — 

1 _ Q _ Q 

4)0 _ 4 _ 4 

— 1 — 1 

Sugar of milk 5 

— 6 — 1 

Therefore if we wish to make up five bottles of six 
ounces, or thirty ounces of a mixture containing no 
fat, 6 per cent, sugar and 1 per cent, protein, we 
would take seven and one-half ounces skim milk, and 
twenty-two and one-half ounces of water, except that 
we will replace one and one-half ounces of the water 
with lime water, giving us twenty-one ounces of 
water and one and one-half ounces of lime water. 
We also add 5 per cent, sugar, which gives us one and 
one-half ounces of sugar. Our formula then will 
read as follows: 

Skim milk 7% ounces 

Water 21 ounces 

Lime water 1% ounces 

Sugar of milk 1% ounces 

By combining these skim milks with different pro- 
portions of whole milk, any formula containing less 
fat than protein may be obtained. Thus to make 
up six bottles of six ounces, or thirty-six ounces of a 
1-6-2 we would use one part skim milk, one part 
whole milk and two parts water, and would need 
4 per cent, of sugar of milk to raise the amount from 
2 to 6 per cent. 



THE MODIFICATION OF MILK 



161 



Whole milk 






4 - 


- 4 - 


- 4 


Skim milk 






- 


- 4 - 


- 4 


Water 






- 


- - 


- 


Lime water 






- 


- - 


- 




4)4 - 


- 8 - 


- 8 








1 - 


- 2 - 


- 2 


Sugar of milk, 


4 


% 




4 





9 ounces 

9 ounces 

17 ounces 

1 ounce 



36 X .04 = loz.,4dr. 



1 



6 — 2 



Again, to obtain five bottles of eight ounces, or 
forty ounces of 1.50 per cent, fat, 7 per cent, sugar 
and 3 per cent, protein, we would use three-fourths 
or thirty ounces of 2 per cent, milk, made from 
equal parts whole milk and centrifugated skim milk, 
adding sugar of milk, 4 per cent, of forty ounces or 
1.6 or one ounce, five drachms. Thus : 



Whole milk 


4 


— 4 


— 4 




Skim milk 





— 4 


— 4 






2)4 


— 8 


— 8 






2 


— 4 


— 4 




Whole milk, 15 ounces 
Skim milk, 15 ounces 


j2 


— 4 

— 4 

— 4 




30 ounces 


Water, 8 ounces 
Lime water, 2 ounces 


1 


— 


— 


10 ounces 




4) 6 


—12 


-12 






1.5 


— 3 


— 3 




Sugar of milk 




4 




1 oz., 5 dr. 



1.5 



An endless number of combinations may be thus 
arranged for whole and skim milk combinations. 



162 



ELEMENTS OF PEDIATEICS 



When more fat than protein is needed, in order to 
get the required proportion between the fat and pro- 
tein, cream or rich milk mnst be diluted. 

Cream. — Cream may be obtained in three different 
ways: 





•Top 


2oz. 


24% Fat 




41" 


20" " 




6k" 

9 " 


16" " 
12" " 




. •• 


10 - 


10" " 




14 " 


S" - 




20 " 


6" " 




24 


5* " 



FIGURE 38. 
Chapin 
Dipper. 



FIGURE 39. 

Fat Content of the Different Layers of 

a Quart Bottle of Milk. 



1. If a milk laboratory is available a percentage 
cream of the required amount may be ordered de- 
livered each day. 

2. In cities where milk is delivered in quart bot- 
tles, a sufficiently accurate percentage cream may be 
obtained by removing with a Chapin dipper (Figure 
38), a certain number of ounces from the top of a 



THE MODIFICATION OF MILK 163 

bottle of milk which has been left standing nntil a 
clearly defined cream line has formed. The top two 
ounces will give a 24 per cent, fat; the top fonr and 
one-half ounces, 20 per cent, fat ; the top nine ounces, 
12 per cent, fat ; top ten ounces, 10 per cent, fat ; top 
fourteen ounces, 8 per cent, fat; top twenty ounces, 
6 per cent, fat; top twenty-four ounces 5 per cent, 
fat. (Figure 39.) 

3. If a quart milk bottle is not available, gravity 
cream skimmed from a pan of milk that has stood 
twelve or twenty-four hours may be used. Such 
skimmed cream usually has about 16 per cent, 
fat and is thus a 16-4-4. By combining this with 
whole milk, 4-4-4, in different proportions, a cream 
of any desired percentage may be obtained. Two 
parts cream and one part milk will give a 12 per 
cent, cream : 

16—4—4 

16—4—4 

4—4—4 

3 )36 — 12 — 12 

12—4—4 

Equal parts milk and cream will give a 10 per cent, 
cream : 

16 — 4 — 4 
4—4 — 4 

2)20 — 8 — 8 



10 — 4 — 4 



One part cream and two parts milk an eight per cent, 
cream, and one part cream and five parts milk a 6 
per cent, cream. 



164 ELEMENTS OF PEDIATEICS 

The problem of the preparation of modifications 
containing more fat than protein is the same as in 
those with equal fat and protein or less fat than 
protein. 

If we wish five bottles of seven ounces, or thirty- 
five ounces of 3-6-1.50 we note that it calls for twice 
the amount of fat as protein. Thus we would use 
an 8 per cent, cream, 8-4-4, which must be diluted 
in the proportion of two-fifths cream to three-fifths 
diluent to obtain approximately the formula desired. 
Thus: 

8 — 4 — 4 

8 — 4 — 4 

_0 — 

_ — 

— Q _ Q 

5) 16 — 8 — 8 

3% - 1% - 1% 

We must raise the sugar from about V/2 to 6 per 
cent., or add 4% per cent, of thirty-five ounces, or 
1.57 ounces, or about one ounce and four drachms. 
The formula would then read : 

8 per cent, cream 14 ounces 

"Water 19 ounces 

Lime water 2 ounces 

Sugar of milk l 1 /^ ounces 

To make six bottles of four ounces, or twenty-four 
ounces, of a l%-6-I, we must have a cream for 
dilution having one and one-half times as much fat 
as protein, or a 6 per cent, cream, 6-4-4. It is 



THE MODIFICATION OF MILK 165 

evident from the previous examples that this must 
be diluted with three parts water and the sugar 
raised from 1 to 6 per cent., or 5 per cent, must 
be added or 1.2 ounces or one ounce, one and one-half 
drachms. Thus the directions would be: 

6 per cent, cream 6 ounces 

Water 17 ounces 

Lime water 1 ounce 

Sugar of milk 1 ounce, V/ 2 drachms 

Formulae for different ages. — A baby a few days old 
can usually be fed on a formula calling for a one- 
fourth dilution of milk or cream or top milk, with 5 
per cent, sugar added. That is a 1.6.1, or a 2.6.1, 
or a 3.6.1. By a month or six weeks usually one- 
third milk or cream may be used, with 5 per cent. 
sugar added, that is 1%.6%.1%, or of a cream modi- 
fication 2%.6%.1%, etc. By three to five months 
equal parts milk and diluent can usually be fed. 
The proportion of milk is gradually increased so that 
by the ninth or twelfth month whole milk is fed. 
These directions, however, do not apply to delicate 
or sick babies. 

APPAEATUS NECESSARY FOR MODIFICATION 

Before preparing modifications of milk in the 
home the following articles should be obtained: 

1. A two quart porcelain pitcher. 

2. A one quart glass graduate. 

3. A sugar of milk graduate which will measure 
weighed quantities of sugar of milk. (Figure 40.) 
A spoon is very inaccurate. 



166 



ELEMENTS OF PEDIATEICS 



4. One or two dozen bottles so designed as to be 
readily kept clean. Those designed by the writer 
(Fignre 41) answers the purpose well, being con- 
structed with a large opening, no neck and a trun- 
cated cone leading to the body of the bottle, instead 
of a truncated sphere. 






FIGURE 40. 

Sugar of Milk 
Graduate. 




FIGURE 41. 

Sanitary Nurs- 
ing Bottle. 



5. One or two dozen nipples of simple design, 
which can readily be turned inside out, so that they 
may be kept perfectly clean. 

6. A small glass funnel for pouring the milk from 
the pitcher or graduate into the bottles. 

Preparation of modified milk. — The required 






THE MODIFICATION OF MILK 167 

weight of sugar of milk should first be measured in 
the sugar of milk graduate, and this should be mixed 
with the specified amount of lime water, 1 and to this 
the water or other diluent should be added. No 
milk should be added until the sugar of milk is en- 
tirely dissolved, for the milk renders the mixture 
opaque, and it is essential that all the sugar should 
be in solution. On addition of the milk it should be 
thoroughly mixed in the pitcher, and the prescribed 
amount poured accurately into each bottle. A small 
funnel inserted in the neck of the bottle will prevent 
the spilling of milk in filling the bottle. The bottles 
should be stoppered with non-absorbent cotton. 

i Lime water is added to milk modifications because it is alkaline 
and it neutralizes the increased acidity of cow's milk. 



CHAPTER XVII 

\ 

THE PASTEURISATION OF MILK 

The question now arises whether this milk should 
be fed raw or should be sujected to heat, in order 
to pasteurise it and make it safer. About 1890 
almost all milk used for infant feeding was sterilised 
at a boiling temperature and such sterilisation is 
still used in Europe. With the obtaining of a clean 
milk in this country and the spread of an unfounded 
idea that heated milk is less nutritious, much raw 
milk has been fed. It has, however, been demon- 
strated recently that a very slight amount of heat 
applied to milk, if continued for a long time, kills the 
bacteria causing typhoid fever, diphtheria, tubercu- 
losis and other diseases, without impairing in any 
way the quality of the milk. (Figure 42.) It also 
has the advantage of securing the sterilisation of the 
sugar of milk, which is not a clean product, and of 
the lime water and the bottle. It neither alters the 
ferments (Figure 43) nor the taste of the milk, nor 
make's any material chemical change in the milk that 
has been discovered, and neither does the writer be- 
lieve that children fed on this milk are in any way 
more liable to rachitis, scurvy or any other nutri- 
tional disease. 

168 



THE PASTEURISATION OF MILK 169 

Those who feed raw milk assume that what we call 
clean, raw milk, especially certified milk, is a safe 

FIGURE 42. 

TABLE OF THE THERMAL DEATH-POINT, IN A 
MOIST MEDIUM, OF CERTAIN PATHOGENIC 
BACTERIA 



Species 






Exposures 


Observer 


Spirillum cholerse 


60° 


C. 


for ten minutes 


Kitasato 


Asiaticse. 


59° 


C. 


for one minute 


Van Geuns 




54° 


C. 


for five minutes 


Van Geuns 




52° 


C. 


for four minutes 


Sternberg 


Streptococcus pyo- 


52° 


C. 


for ten minutes 


Sternberg 


genes. 










Bacillus typhosis. 


60° 


C. 


for five minutes 


Buchner 




60° 


C. 


for one minute 


Van Geuns 




57° 


C. 


for five minutes 


Janowski 




56° 


C. 


for ten minutes 


Sternberg 




56° 


c. 


for five minutes 


Van Geuns 


Bacillus diphtheria?. 


58° 


c. 


for ten minutes 


Welch and 
Abbott 


Staphylococcus pyo- 


56° 


c. 


-58° C. for ten min- 


Sternberg 


genes aureus. 






utes 




Bacillus coli commu- 


60° 


c. 


for ten minutes 


Weisser 


nis. 
Pneumococcus 


56° 


c. 




Sternberg 




60° 


c. 


for one minute 


Van Geuns 


Bacillus tuberculosis. 


70° 


c. 


for one minute 


Grancher and 
Lidoux-Libard 




70° 


c. 


for ten minutes 


Yersin 




68° 


c. 


-68% C. for twenty 
minutes 


Bitter 




65° 


c. 


for fifteen minutes 


Forster 




60° 


c. 


for twenty minutes 


Bonhoff 




60° 


c. 


for fifteen minutes 


Schroeder 




55° 


c. 


for four to six hours 


Kolle and 
Wassermann 



food for babies : that pasteurisation of milk induces 
scurvy in babies and interferes with their nutrition 
by changes that it produces in the milk. 



170 



ELEMENTS OF PEDIATRICS 



Temperature of pasteurisation. — The temperature 
at which pasteurisation is accomplished has been 

FIGURE 43. 

THE EFFECT OF HEAT ON CERTAIN BIOLOGIC 
CHARACTERISTICS OF MILK AS DETERMINED 
BY HIPPIUS 

Unchanged 

by 

1. In Woman's Milk. 

Salol-splitting ferment 

fl hr. at 

140° F 
Amylolytic ferment "i v h t 

[ 149° F. 



Weakened 
bv 



Destroyed 

by 



140°-149° F. 151° -fF. 



158° F. 
short time 



167° F. 



2. In Woman's Milk 


Less 












Active in Cow's Milk. 












Fat-splitting ferment 


143° F. 


145° F. 


147° F. 


3. Active in Woman's 


and 












Cow's Milk. 




'I 


hr. at 








Proteolytic ferment 


1 


% 


140° F. 
hr. at 
149° F. 






Boiling 


Oxidizing ferment 




^1 


hr. 140° 
149° F. 


f% 


hr. at 


1 minute at 
169° F. 


Bactericidal action 








I 


149° F. 
min. at 
185° F. 


Boiling 


Alexins according 


to 








hr. at 




Von Behring 








149° F. 


Boiling 










min. at 












I 


185° F. 




Lactoserum 




1 


hr. at 
248° F. 









gradually reduced with increasing knowledge of the 
thermal death point of the bacteria that we feared in 
milk. So that now we know that a temperature of 



THE PASTEURISATION OF MILK 171 

140° Fahrenheit continued for forty minutes, is suf- 
ficient to destroy these bacteria, including the tuber- 
cle bacillus, without producing any chemical change 
in the milk, or altering its taste. The thermal death 
point of these bacteria is shown in the table. (Fig- 
ure 42.) 

Both human and cow's milk contain many fer- 
ments which have been studied and which may be of 
value in the assimilation of milk by the child. 
These are tabulated (Figure 43), with information 
as to the influence of different temperatures on their 
activities, and it is seen that a pasteurising temper- 
ature would not destroy and would scarcely weaken 
any of them. When the milk is pasteurised in the 
nursing bottle it gives one a security that can be 
obtained in no other way. Moreover, any danger of 
scurvy is readily obviated by the administration of 
orange juice daily after the fifth month. 

Pasteurisation can be accomplished without the 
use of an apparatus or thermometer at about 160° 
Fahrenheit, by watching undiluted milk being heated 
until a film forms. It may then be so placed as to 
retain its temperature for fifteen minutes and then 
rapidly cooled. By this method a temperature of 
some fifty degrees below the boiling point is used, 
and some of the damage done to the milk by a high 
temperature avoided. 

It is, however, unnecessary to use so high a tem- 
perature, but if a lower temperature is used, a longer 
duration must be sustained. Any desired temper- 
ature may be produced by heat in milk controlled by 



172 ELEMENTS OF PEDIATRICS 

a thermometer, and, so far as possible, this may be 
sustained by a modification of exposure to heat. If 
the lowest possible efficient temperature is desired, 
that is, 140°, it should be sustained, if possible, for 
forty minutes, and facilities for rapid cooling should 
be furnished. The simplest method of accomplish- 
ing such pasteurisation is by means of an apparatus 
devised by the author, which requires neither watch- 
ing nor the use of a thermometer. 

The pasteuriser. — This pasteuriser consists of a 
pail (Figure 44), in which a measured amount of 
water is boiled, and a receptacle for the bottles, in 
which the bottles, when filled, are placed, surrounded 
by cold water. When the water in the pail boils 
vigorously, the pail is taken from the stove and 
placed on any non-conducting surface, such as the 
floor or rug, and out of a draft. The cover is re- 
moved and the receptacle containing the bottles 
quickly inserted ; the cover is replaced and the pail is 
allowed to stand undisturbed for an hour. An 
equalisation of temperature between the measured 
amount of boiling water and the cold milk takes 
place so that at the end of fifteen minutes the pas- 
teurising temperature is reached and persists until 
the end of an hour. The pail is then uncovered and 
set into a sink where cold water is allowed to replace 
the hot water and in twenty minutes the bottles are 
at about the temperature of the water used, and are 
ready to be placed in the refrigerator. 

The two lines on the chart (Figure 45) show the 
temperatures of bottles of milk in the pasteuriser. 



THE PASTEUEISATION OF MILK 173 

The upper line indicates a bottle inserted in the pas- 
teuriser at a temperature of 17° C, which reaches 
in twenty minutes a temperature of 62° C. (147° F.), 
in thirty-five minutes a temperature of 64° C, which 
it nearly retains for sixty minutes, when the pail is 
uncovered and the cold water added, so that in five 
minutes the temperature is reduced to 28° C. 





1. 2. 

1. Apparatus arranged for heating the milk before the pail is covered. 

2. Apparatus arranged for cooling the milk. 

FIGURE 44. 
Pasteuriser. 



The second line indicates the result when the milk 
is much colder, so that beginning with a temperature 
of only 10° C. we have in twenty minutes a temper- 
ature of 60° and a maximum temperature at thirty- 
five minutes of 62°, which is nearly held until sixty 
minutes, when a rapid decline during cooling takes 
place to 28° C. 

It is thus evident that a variation in temperature 



174 



ELEMENTS OF PEDIATEICS 



of ten degrees, when the milk is put in the pasteur- 
iser, is reduced to a difference of only two degrees in 
the resultant temperature during pasteurisation. 



TEMP. 
C. 

65 
60 
55 
50 
45 
40 
35 
30 
25 
20 
15 
10 


Time in Minutes 
5 10 15 20 25 30 35 40 45 50 55 60 65 70 






































^ 


^^ 
















\ 








































/ 


/ 


























J 


/ 
















































































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1 
































^\ 
































v~ 





























































































FIGURE 45. 
Temperatures During Pasteurisation of a Bottle of Milk at 10° C. and a 
Bottle of Milk at 17° C. Showing the Elimination During Pasteur- 
isation of an Initial Variation in Temperature of 7° to a Resultant 
Variation in Temperature of 2°. 

This is due to the fact that a measured amount of 
boiling water will elevate the temperature, increas- 
ing proportionately to the degree of cold in the milk. 



THE PASTEUBISATION OF MILK 175 

Commercial pasteurisation. — It is possible now in 
many cities to buy so-called pasteurised milk, but 
this milk is not to be recommended for infant feed- 
ing, because it is not produced under as good condi- 
tions as certified milk, and also has a much higher 
bacterial count. This pasteurisation has often been 
done at a much higher temperature than is necessary 
and kept at this temperature only momentarily. In 
New York now milk is pasteurised at 140 to 145 de- 
grees Fahrenheit for twenty minutes in large vats. 
This milk is re-contaminated either in bottling or by 
the bottles into which it is put after pasteurisation. 
At the present time it contains on the average some 
thirty-five thousand bacteria per cubic centimeter, 
while certified milk averages less than five thousand, 
and that from one herd supplying New York only 
four hundred. 



CHAPTER XVIII 

METHODS OF ABTIFICIAL FEEDING 

In the artificial feeding of babies the same inter- 
vals of feeding (page 102) and regulations should be 
observed as in breast feeding. The child should 
take a feeding in not less than ten minutes and not 
more than twenty minutes. The length of time 
taken over the bottle is regulated by the size of the 
hole in the nipple and the elevation of the bottle 
during feeding. The nipple should be a simple one 
without valves and so constructed that it can be 
turned inside out, otherwise desirable cleanliness 
in the care of the nipple is impossible. 

The bottle should be held by the nurse during the 
entire time of feeding, it should never be propped up 
or put on a stand. As the baby empties it, the bot- 
tom should be raised so that no air can enter the neck 
of the bottle from which the baby sucks. 

Estimation of caloric requirements. — The applica- 
tion of modifications of milk to the requirements of 
any special infant during the first year of life must 
be based on the age, weight, activity, stomach ca- 
pacity, caloric needs, and the ability for digestion 
and assimilation of that particular infant. Each one 
of these factors must receive attention. It may be 
said, however, that the caloric needs of an emaciated 

176 






METHODS OF AETIFICIAL FEEDING 177 

baby of several months of age is much more accur- 
ately judged by an estimate based on age than one 
based on weight. 

A rough estimate of the stomach capacity has been 
given in a previous section (page 49), but the adap- 
tation of this to any particular infant must be deter- 
mined after trial. 

The caloric needs of babies have been carefully 
worked out, and sufficient knowledge to determine 
whether any baby who is not doing well is obtaining 
its caloric needs, is essential to any one who under- 
takes to feed babies intelligently. 

The caloric needs of an infant at birth are consid- 
ered to be about fifty calories for each pound of 
weight, and at one year thirty-five or forty, so that 
an average baby at birth requires about 350 calories 
of food a day and at a year old about 840. 

One ounce of fat yields 300 calories and one ounce 
of carbohydrates or protein about 130 calories each. 
Any one knowing these facts and the formula he is 
feeding can in a moment ascertain the caloric value 
of the food. 

In an appended table there is worked out (Figure 
46) a scheme for the average feeding of a baby dur- 
ing the first year. 

In the first column is the age; next the average 
weight for that age ; the caloric requirements for the 
weight; a formula adapted to that age and weight; 
the number of feedings; the amount in each feeding; 
the way the formula is prepared from milk ; and the 
caloric value of the formula. 

















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178 



METHODS OF AETIFICIAL FEEDING 179 

It is noticeable that during the first month rather 
less than the theoretical caloric needs are apt to be 
fed, although if the child can digest it, and seems to 
need it, more may be given. For the balance of the 
year we are apt to feed considerably more than the 
caloric needs if the child can digest it. In difficult 
cases, however, we endeavour to keep up to or some- 
what above* such caloric needs. Thus, referring to 
the table, an average child at one month with a 
weight of nine pounds should have about 450 calories. 
A milk containing 3 per cent, fat, 7 per cent, sugar 
and l/{> per cent, protein would be a fair feeding, 
while seven bottles of three ounces or twenty-one 
ounces would represent a moderate amount. It is 
evident since the fat is twice as much as the pro- 
tein, that an 8 per cent, cream should be used, and it 
is found that if three parts of this are taken and five 
parts of diluent that the required formula is ob- 
tained. The caloric value of this food is ascertained 
in the following manner : 

Our food contains twenty-one ounces of which 3 
per cent, or .63 of an ounce is fat. If one ounce of 
fat has a caloric value of 300, .63 will have a value of 
189 calories. The protein and carbohydrate hav- 
ing the same caloric value may be estimated together, 
and by adding 7 and 1% we have 8% per cent., or 1.78 
of an ounce of carbohydrate and protein in our for- 
mula. Since the value of these is 130 calories an 
ounce, we have a caloric value of our sugar and pro- 
tein of 231, or a total caloric value of 420. 

It is seen by the table (Figure 46) that starting a 



180 ELEMENTS OF PEDIATRICS 

baby during the first three days on two ounces of a 
simple 4 per cent, sugar solution every two hours for 
ten feedings, at the end of the week we may run the 
formula up to 1 per cent, fat, 6 per cent, sugar and 
1 per cent, protein, giving only 8 feedings of 2 ounces. 
At a month we may give 3 per cent, fat, 7 per cent, 
sugar and 1% per cent, protein, with 7 feedings of 3 
ounces; at three months, we may feed 3% per cent, 
fat, 6 per cent, sugar and 3 per cent, protein, with 
six feedings of four ounces. This formula then is 
gradually advanced and at the end of the year all 
diluents are abandoned and the child gets &ve bottles 
of nine ounces of whole milk. 

This table simply indicates what certain healthy 
children might take, but it is only a rough indication, 
each child being given what it needs and what it can 
digest. The fat in many of these formulae is too 
high for some children, so that if a child shows any 
indication of fat indigestion through gastro-intesti- 
nal disturbance, with white stools, the fat should be 
reduced. In some children high sugar causes vomit- 
ing and acid stools, and in these cases the sugar 
should be reduced. Other children with poor pro- 
tein digestion and putrid stools should have a reduc- 
tion in the amount of protein in the food, while any 
child who vomits must usually have the total amount 
of food in each bottle reduced or a change made in 
the food. 

Persistent vomiting in babies may be due to too 
much food or to an element in the food which is 
unsuitable to that baby, or to a pyloric spasm or 



METHODS OF ARTIFICIAL FEEDING 181 

stenosis, or to some acute disease. The first indica- 
tion in persistent vomiting is to reduce the amount 
of food and often to lengthen the interval between 
feedings. If this is not successful and especially if 
the movements are sour, all sugar may be taken from 
the feedings for a day, or if this does not rectify the 
trouble a day without fats may be tried. Should 
these changes give no relief, stomach retention 
should be investigated by means of a stomach 
tube. 

The first feeding ordered for any baby is, as has 
been stated, usually rather lower than it is thought 
the baby can take, and then it is gradually raised in 
accordance with the demands of the baby's appetite 
and the indications of the weight chart. In labo- 
ratory feedings the changes are usually made by 
advances of a quarter of 1 per cent, in those ele- 
ments in which it is thought advisable. The usual 
maximum of fat for babies under six months is 3 
per cent., in sugar 7 per cent., and in protein 2 per 
cent. 

In home modification, the changes are made in a 
different way. Take, for instance, the last feeding 
which was made with six ounces of 6 per cent, cream, 
or the top twenty ounces of a quart bottle of milk, 
one could increase the fat by taking the top eighteen 
or sixteen ounces, thus using the same amount of a 
richer cream, or raise both fat and protein by using 
more of the top twenty ounces, six and one-half or 
seven or more ounces, or one could raise the pro- 
tein without raising the fat by taking six and one- 



182 ELEMENTS OF PEDIATRICS 

half or seven ounces of the top twenty-two or twenty- 
four ounces. 

Orange juice. — In the foregoing we have summar- 
ised what we may term normal feeding of the baby, 
with the exception that all babies who are artificially 
fed should, after the first three months have, in addi- 
tion to their feedings, a certain amount of orange 
juice, for no baby who is given this in sufficient quan- 
tity has scurvy, while all other artificially fed babies 
are liable to it. In the administration of orange 
juice, if given early, iive to ten drops each day are 
sufficient, a few days afterward a coff eespoonful and 
later a teaspoonful or a tablespoonful or more. It 
is customary to give this one hour before one of 
the morning feedings, and this is all that should be 
given between feedings except water, which may be 
given at the same interval before any other feed- 
ing. 

Milk laboratories. — In cities that afford the facili- 
ties of milk laboratories for the feeding of infants 
they should be used, where people can afford this 
luxury, on account of the greater accuracy in the 
preparation and handling of the milk, and the fact 
that it takes from the nurse a certain amount of 
detail work which usually limits the amount of time 
that the baby can be kept out of doors. 

These laboratories will undertake to supply daily 
in sterilised nursing bottles any modification and 
amount ordered, according to the prescription writ- 
ten by the physician. A sample (Figure 47) of a 
prescription is as follows : 



METHODS OF ARTIFICIAL FEEDING 183 

FIGURE 47. 

LABORATORY FEEDING PRESCRIPTION 

Take of Fat 3 % 

Lactose 7 % 

Protein iy 2 % 

Lime water 5 % 

Make 6 bottles of 6 ounces. 
Pasteurise at 140° F. for 40 minutes. 
For Baby Smith. 

John Jones, M.D. 

There is almost as much reason why milk labo- 
ratories should be used, when available, as there is 
why drug stores should be used for medicines. The 
same accuracy is desirable in milk modification. 
Changes are more readily made in the formula and, 
therefore, are more often made if indicated. 

The milk laboratories, while prepared to use 
gravity creams in these modifications, ordinarily use 
milk separated by a centrifuge, obtaining thus a 
cream with a higher percentage of fat and a skim 
milk with a lower percentage of fat, which is desir- 
able for some modifications. 

FEEDING OF DIFFICULT CASES 

We have taken up the methods for the normal feed- 
ing of children with a fair or good digestion, and will 
pass now to a consideration of our resources for 
feeding babies who will not thrive on the sort of 
feedings we have already described. Failures, how- 
ever, with the preceding feedings are often due to 
lack of facility on the part of the physician to so ad- 
just the amount and ingredients as to fit the require- 



184 ELEMENTS OF PEDIATEICS 

ments of the baby. An excellent illustration of this 
was related concerning a young physician in one of 
the hospitals, who after feeding a baby on many 
different f ormulse, at last, in despair, resorted to con- 
densed milk on which the baby thrived. During a 
visit from his superior he showed this baby to him 
remarking that he had been unable to make it thrive 
on modified milk. He was told to work out the for- 
mula he was giving in condensed milk, and make it 
up from fresh milk, and that the baby would do as 
well as on condensed milk. On doing this, he had no 
further trouble with feeding modified milk, and was 
using a much better food for the baby and one from 
which he could more readily pass to a modification of 
milk that did not contain an excess of cane sugar. 

Cereal diluents. — The use of cereal decoctions in 
place of water for diluting the milk has proved a 
great aid to the digestion of milk in many infants. 
The objection has been raised against the use of these 
cereal decoctions in early life, that infants have no 
digestive capacity for starch, and although there is 
conflicting evidence on this point, we now believe 
that they have some digestive capacity for starch, 
and whether they have or not, we know from clinical 
experience that even in the first days of life, if the 
breast milk is not well digested, an improvement is 
often obtained if a little barle}^ water is given before 
the nursings. These cereal decoctions supply a 
mucilaginous material which stimulates the secre- 
tion of the gastric juice, and modifies materially the 
size of the curds which the milk forms in the infant's 



METHODS OF AETIFICIAL FEEDING 185 

stomach. Their food value is very slight. Thus 
barley water of the usual strength contains only 1% 
per cent, starch and an insignificant amount of fat 
and protein. (Figure 48.) 

FIGURE 48. 

ANALYSIS OF BARLEY WATER 

Starch 1.63 

Fat 05 

Protein .' 09 

Inorganic salts .03 

Water 98.20 



100.00 



Inasmuch as many children digest the modified 
milk with cereal diluents better than without, the use 
of such diluents instead of simple water may be 
recommended. In preparing the cereal diluents the 
cereal ground into flour is to be preferred on account 
of the greater ease in preparing it. Whether the 
cereal be barley, oatmeal, cornmeal or a legume, we 
use ordinarily a rounded tablespoonful of the flour to 
a quart of water, boil in a double boiler for one hour 
and strain through cheesecloth, or a fine strainer. 

These cereal decoctions also have an important 
place in feeding sick children, particularly where 
milk is temporarily abandoned, and in that case they 
may be made much stronger and dextrinised by the 
addition of malt, which will make quite thin a very 
thick cereal decoction that would not otherwise pass 
through the nipple. So if it is necessary to keep the 



186 ELEMENTS OP PEDIATRICS 

child many days on cereal decoctions without milk, 
one may dextrinise and increase the strength. The 
strength can be increased to such an extent that these 
cereal decoctions have almost the nutritive value of 
milk, but my experience has been that while babies 
often gain well on such dextrinised cereal decoctions, 
this gain generally does not continue for more than 
ten days or two weeks, and if persistently fed on this 
alone they are liable to lose as fast as they have 
gained, or faster. 

Legume or bean cereal has been recently recom- 
mended, especially because it contains more protein 
than other cereals. On the other hand, children do 
not, as a rule, like it and are often upset by it. 

Peptonising. — The peptonising of milk is an aid to 
digestion and is particularly useful when curds are 
seen in the stools. There has been a good deal of 
controversy in pediatric literature recently concern- 
ing the character of curds and the evidence seems to 
favour the fact that the curds seen during the first 
months contain little protein, but fat, fatty acids and 
soap. They seem, however, to be an evidence of 
poor protein digestion and efficient protein digestion 
often results in the disappearance of curds. Of the 
methods for improving protein digestion and elim- 
inating curds peptonising is one of the most im- 
portant. The effect of the trypsin and soda powders 
contained in the peptonising tube, if they are allowed 
to act in warm milk for fifteen or twenty minutes, is 
to predigest the protein of milk. A much more 
marked peptonising effect may be obtained by a 



METHODS OF AETIFICIAL FEEDING 187 

longer duration, but the milk then becomes bitter and 
distasteful and can ordinarily only be used by forced 
feeding with the stomach tube. 

There is possibly another reason why children 
often gain better when the milk is peptonised, besides 
the predigestion of the milk, for the administration 
of pancreatic extract in some children, and for that 
matter in some adults, will increase the weight by 
providing for a more thorough absorption of food. 
In such cases there is probably a lack of activity in 
the pancreatic gland of the individual. 

Whey. — A still more effective means of improving 
protein digestion is by the use of whey instead of 
whole milk protein. As already stated, the protein 
of breast milk consist of two-thirds la ct albumin, 
which forms in fine curds and only one-third casein- 
ogen, which forms in tough curds. In cow's milk, 
on the contrary, the caseinogen is five-sixths of the 
protein and the lactalbumin only one-sixth, thus Ave 
have large hard curds of cow's milk, which do not 
occur in mother's milk. Fortunately we can separ- 
ate the caseinogen, which is in suspension, from the 
lactalbumin, which is in solution, by the use of rennet, 
which added to warm milk causes the curdling in a 
large mass of the caseinogen, leaving the lactalbumin 
a thin fluid that is easily strained off. The best 
whey is made from skim milk and to be at all pure 
the whey should be extracted from the milk without 
pressure. Slight pressure will add to the whey a 
considerable amount of caseinogen. Whey, when 
properly made from skim milk, will contain no Pat, 



188 ELEMENTS OF. PEDIATRICS 

about 4 per cent, sugar and about .8 per cent, 
protein, and while we may with success feed this to 
sick children its caloric value is not sufficient for a 
constant diet. When this is added to cream, we can 
obtain a food nearly .8 per cent, of the protein 
of which is of this digestible whey and the fat and 
balance of the protein whatever we desire to have 
them. If we wish to keep the protein low we add 
the fat in the form of a very rich cream, but if 
we wish to add whole milk protein we use a cream 
containing less fat. The feeding of whey milk is 
particularly applicable to very young babies and the 
change from a simple modification of milk to a whey 
milk will often immediately cure a severe colic of a 
young baby or will effect a gain in weight in a child 
who has failed to gain or who has been losing. 
When, as in older children, we wish to feed two or 
more per cent, of protein, the proportion of whey 
protein in the mixture is so small that' little ad- 
vantage is gained by feeding a whey-cream mixture. 
Sometimes a child who has been on a barley water 
diluent will have more colic when put on a whey- 
cream mixture, in which case one may introduce one 
or two ounces of a thick barley jelly into the mixture. 
Unfortunately the preparation of such milk is rather 
complicated and not readily made at home unless 
there is an intelligent and expert nurse in the house- 
hold. 

Two examples follow of the way that modifications 
of whey milk may be worked out. 

In a young baby, where one wishes to feed eight 



METHODS OF ABTIFICIAL FEEDING 189 

bottles of two ounces or sixteen ounces of a modifica- 
tion containing 2 per cent, fat, 6 per cent, sugar and 
1 per cent, protein, if we use one part 32 per cent, 
cream and fifteen parts whey our required for- 
mula will be obtained, except that we must add 2 per 
cent, sugar, 2 per cent, of sixteen ounces be- 
ing one-third of an ounce or two drachms. Exam- 
ple: 



8 bottles of 2 ounces =16 ounces of formula containing 2 per cent, fat, 
6 per cent, sugar, and 1 per cent, protein 

1 part 32 per cent, cream or 32 — 4 — 4 = 32 — 4 — 4= 1 ounce 
15 parts whey or — 4 — .8= — 60 — 12 = 15 ounces 

16) 32 — 64—16 



2— 4— 1 
2 per cent, sugar = 2 drachms. 2 



2— 6— 1 

If later a stronger modification is required a cream 
with a lower fat content would be used. 

If seven feedings of four ounces each or twenty- 
eight ounces were needed a mixture containing 2% 
per cent, fat, 6 per cent, sugar, and 1 V± per cent, pro- 
tein might be obtained in the following manner : 



4 oz. 

24 oz. 



1 part gravity cream or the 
top 6 oz. of a bottle of milk 
6 parts Avhey or 


16—4 — 4 = 16— 4 — 4 
— 4— .8= — 24 — 4.8 


Sugar 2 per cent, of 28 oz.= 


7) 16 — 28 — 8.8 
2%— 6 — 1H 
= about y-2 oz. 2 



2% _ 8-11/4 



190 ELEMENTS OF PEDIATRICS 

Buttermilk. — For many years buttermilk, that is, 
soured skim milk, has been used with success in cer- 
tain institutions for babies in Europe. 

This buttermilk was used, in all probability, be- 
cause it was a refuse product from the manufacture 
of butter, which could be bought for little and had a 
good nutritive value. It was reported that children 
fed upon it did well. Since the recent popularity of 
buttermilk, associated with the enthusiastic commen- 
dation of Metchnikoff, it has been tried to some 
extent in infant feeding. 

In many children when the stools are very offen- 
sive or there is much gas expelled with the move- 
ment, and especially when this condition is asso- 
ciated with the presence of indican and phenol in the 
urine, buttermilk may be of great value. It is well 
to secure a brand of buttermilk that is not allowed to 
become very sour and this may be mixed at first with 
sweet milk, beginning with a small addition of but- 
termilk and increasing the proportion gradually as 
the child becomes accustomed to it. If the butter- 
milk is not well taken, a lacto-bacillary culture may 
be used. Better than ordinary buttermilk is prop- 
erly prepared lacto-bacillary milk. This is made 
from skim or partly skimmed milk, which is first pas- 
teurised and then planted with the bacillus Bulgari- 
cus. This may be obtained from the milk labora- 
tories. 

Finklestein milk. Eiweiss milk. Protein milk. — 
A modification of milk containing buttermilk which 
was recommended by Finklestein has recently been 






METHODS OF AETIFICIAL FEEDING 191 

used extensively. This milk is prepared as follows : 
A quart of whole milk is made lukewarm and pepsin 
or rennet is added to coagulate it. After filtering off 
the whey, the curd, ordinarily known as junket, is 
passed several times through a fine sieve, to this a 
pint of water is added and then a pint of butter- 
milk. 

This Finklestein milk has the characteristic of con- 
taining a small amount of milk sugar, a moderate 
amount of fat, a considerable amount of protein, and 
the living lactic acid bacilli. It is, moreover, very 
palatable. Its formula is fat, 2% per cent.; sugar, 
1% per cent.; protein, 3 per cent.; and it has a fair 
caloric value. 

It is useful in some babies who are vomiting, or 
having diarrhoea with offensive stools, but babies do 
not gain in weight while on this food, unless sugar is 
added, for in children who can take it, milk sugar 
is a most important element of the food, containing 
the same caloric value as protein and being more 
thoroughly digested, with much less labour on the 
part of the infant. Thus it is possible to feed many 
times more sugar than protein, and have apparently 
no sugar in the stools, while of protein a consider- 
able percentage is always present in the stools. 

The indication for Finklestein milk may be ful- 
filled by feeding an appropriate formula and giving 
in addition, several times a day, a good lacto-bacil- 
lary culture, or by the addition of a moderate amount 
of buttermilk to the formula. 

Maltose. — For children who are not gaining on a 



192 ELEMENTS OF PEDIATRICS 

normal formula with a sufficient amount of sugar of 
milk, or children who vomit when sugar of milk is 
fed, or who are constipated, the use of maltose in- 
stead of lactose often gives most satisfactory results. 
This is readily accomplished by substituting for the 
4 or 5 per cent, of added sugar of milk an equal 
amount of dextri-maltose or malted milk, which 
latter gives, in addition to the maltose, some protein 
food and an insignificant amount of fat. In many 
cases children who have failed to gain on other food 
will immediately show a marked gain as soon as this 
change is made. Either a dry or moist form of 
maltose may be used. Mead's dextri-maltose is a 
convenient form of the dry dextri-maltose and con- 
tains 51 per cent, maltose and 47 per cent, diatase. 
Certain children, who do not gain well or are, con- 
stipated on a dry dextri-maltose preparation ap- 
parently do better when one of the moist prepara- 
tions are used. 

Malt soup. — A food that depends for its popularity 
on the comparatively large amount of malt sugar it 
contains is the malt soup advocated by Keller. As 
the liquid malt extract in the food is cooked with the 
milk and as ordinary malt extract has an acid re- 
action, which would curdle the milk, a neutralised 
malt extract is used. To an ordinary malt extract 
about five grains of carbonate of potash are added to 
each ounce. A common proportion for feeding, if 
using five bottles of eight ounces, or forty ounces, is 
as follows : 



METHODS OF ARTIFICIAL FEEDING 193 

Mixed milk 20 ounces 

Water 18 ounces 

Neutralised malt extract 2 ounces 

Wheat flour 2 ounces 

The proportion of these ingredients may be varied. 
For very young babies only one-third milk may be 
used, while for those of nine months two-thirds milk 
may be used. Also for infants with poor sugar tol- 
erance less than two ounces of malt extract may be 
well taken, while others may take more. The objec- 
tion to this food is that a. large amount of sugar is 
often fed. It is, however, a very useful resource in 
some babies who are difficult to make gain in weight. 

There is one class of babies in which malt makes 
the bowels too loose and the waste from the bowel in 
this way is sufficient to cause a loss in weight instead 
of a gain. But in most cases the movements are 
simply soft, of normal frequency, of a brown colour, 
and often with a malt odour. 

A convenient way to prepare malt soup is to use 
Loeffland's malt soup or maltine, or neutralised 
maltzyme, in which the carbonate of potash is com- 
bined with the malt extract. 

Cane sugar. — In some infants a better result may 
be obtained by the use of cane sugar in place of 
sugar of milk. 

The tolerance of cane sugar in some infants is 
shown by the good results obtained in putting babies 
on condensed milk, when on a dilution of one to six- 
teen they obtain only % per cent, protein, but little 



194 ELEMENTS OF PEDIATEICS 

more fat and 3 per cent, sugar, mostly cane sugar, 
while on the one to eight dilution the amount of fat 
is but little more than 1 per cent., protein 1 per cent., 
and sugar 6 per cent., 5 per cent of which is cane 
sugar. 

The feeding of condensed milk, therefore, is a feed- 
ing of cane sugar with an insufficient amount of fat 
and protein. While some children will do better on 
cane sugar and many children quite as well, a certain 
number will do very much worse. 

Cane sugar has, however, a place in the feedings 
of babies of the poor, for it is materially cheaper 
than sugar of milk or dextri-maltose and some babies 
do perfectly well when it is added to the food in place 
of other forms of sugar. 

Dry milk. — In those babies whose bowels become 
loose from the administration of malt soup and who 
evidently need a very readily digested form of pro- 
tein and high sugar, and low fat, we have another 
resource in dry milk preparations without the addi- 
tion of malt. 

Attempts to produce milk in a dry form were never 
successful until recently, the dry milk being dry skim 
milk, for the presence of fat in the milk made an im- 
possible preparation. In recent years, however, it 
has been found that by passing milk over a hot cylin- 
der on which it would form a crust, a dry milk could 
be obtained, which contained fat in an unobjection- 
able form. The first dry milk, so far as I know, to 
obtain much reputation was a preparation contain- 
ing 12 per cent, fat, 56 per cent, lactose and 24 per 



METHODS OF ARTIFICIAL FEEDING 195 

cent, protein, and which soon obtained some little 
sale in this country under the name of Mammala. 
There is a similar preparation made in this country 
for infant feeding, but which is less known. Most 
dry milk made in this country is sold to bakers as a 
cheap form of milk. In preparing these dried milks 
which contain fat one must mix the dry milk with the 
required proportion of warm water just before each 
feeding. To make a four ounce bottle, 1% or 2 
ounces of the dry milk preparation may be measured 
in a liquid graduate and the water, somewhat too 
warm for feeding, added to four ounces, or it may be 
made up in the same way in a graduated bottle. If 
an eight-ounce bottle is needed, about four ounces of 
the dry milk preparation, measured in a liquid grad- 
uate, may generally be used. This food is often 
very assimilable in babies who are difficult to feed. 

In changing from such a food to a modification of 
milk, it is best to substitute milk and gruel and sugar 
of milk gradually, increasing, little by little, these 
ingredients as the dry milk preparation is dimin- 
ished in amount. 

When one has intelligently run through the dietary 
resources that have been outlined without being able 
to find a "feeding that fits," he should resort to a 
wet nurse rather than to the proprietary foods to 
which the parents of the child have no doubt re- 
peatedly called his attention during the changes. 

The advertised proprietary foods, while differing 
somewhat in their analyses have certain character- 
istics in common. They all contain very little fat, a 






196 ELEMENTS OF PEDIATRICS 

great deal of sugar or starch, and low protein. 
Some contain sugar of milk and others malt sugar. 
None of them have any advantage over the methods 
of feeding that have been reviewed. 



CHAPTER XIX 

THEORY OF INFANT FEEDING 

The best graphic representation of the principles 
of infant feeding is portrayed in the charts modified 
from those of von Pirquet, particularly with refer- 
ence to the amount of food administered. 

Thus in Figure 49, the upper line represents the 
weight of a child and the perpendicular lines the 
amount of food administered. We notice that a child 
fed on what is designated as the minimum amount of 
food holds about an even weight (Section 1), neither 
gaining nor losing, and that if the food is withdrawn 
for a certain period a rapid loss in weight ensues. 
(Section 2.) Administration of food up to one-half 
the minimum required for the support of life causes 
a less rapid loss in weight (Section 3), while with the 
restoration of the minimum amount of food a prac- 
tically stationary weight is obtained. (Section 4.) 
If then another increase in food is made, a slight 
gain in weight occurs (Section 5), and with a fur- 
ther increase a rapid gain occurs. (Section 6.) 

In the feeding of babies, the smallest amount of 
food which will cause this rapid gain in weight is 
usually the best amount for that child for the time, 
and should be adhered to with slight variations, as 

197 



198 



ELEMENTS OF PEDIATRICS 



changes in tolerance occur, in which way a per- 
sistent gain in weight should be obtained. 

Very often the 
amount of food is 
increased after this 
optimum has been 
given . and with each 
increase a less rapid 
gain in weight takes 
place (Sections 7 
and 8), until finally, 
with a considerable 
increase, a station- 
ary weight results, 
while this over-feed- 
i n g , if continued, 
produces symptoms 
in abnormal move- 
ments, often too fre- 
q u e n t movements, 
sometimes fever, 
and with this a rapid 
diminution i n t h e 
tolerance of the 
child to food. Thus, 
as seen in (Figure 
50) Section 9, the 
tolerance becomes less than the former optimum, 
descending in Section 11 to less than the former 
minimum, while at the same time the weight is grad- 
ually diminished, and finally, if no change in the 




FIGURE 49. 
The Effect on Weight of the With- 
drawal of Food and of the Ad- 
ministration of the Minimum, Op- 
timum and Maximum Amount of 
Food, and an Amount Exceeding 
the Maximum or Tolerance of the 
Child. 



THEOEY OF INFANT FEEDING 199 

food is made, the child loses all tolerance and 
dies. 

The reaction of the child to a modification of the 
amount of food will depend upon how early this 
modification takes place and what the tolerance of 




FIGURE 50. 
The Effect of the Persistent Feeding of Food in Excess of the Maxi- 
mum Amount or Tolerance of the Child, Resulting in A Diminu- 
tion of the Tolerance. 

the child is at the time the food is reduced. Thus if 
the food is reduced to the child's minimum require- 
ment, as in Figure 51, when the tolerance is only 
slightly reduced, the tolerance will immediately in- 



200 



ELEMENTS OF PEDIATEICS 



crease, so that the amount of food can be gradually 
brought up to the optimum with a gain in weight and 
a normal tolerance line. 




FIGURE 51. 

The Effect of Reducing the Food to a Minimum When the Tolerance 

is but Slightly Reduced. 

If, on the other hand, this large amount of food is 
persisted in until a marked reduction in weight has 



THEORY OF INFANT FEEDING 201 

taken place (Figure 52) and the tolerance is still 
above the line of the minimum amount of food neces- 




FIGURE 52. 

The Effect of the Temporary Withdrawal of the Food When the Tolerance 

is Considerably Reduced. 

sary to support life, and the food is cut off entirely 
and then gradually increased, the tolerance will in- 
crease and the child will begin to gain in weight after 




= o 



§ w 



a 

H 
O 

02 
W 
O 

o 

p 



202 



THEORY OF INFANT FEEDING 203 

the amount of food is built up above the minimum. 

In case, however, the reduction in the amount of 
food (Figure 53) is delayed until Section 11 of Fig- 
ure 50, where the tolerance line is far below the 
minimum of food necessary to support the body, 
there may be some reaction from starvation and a 
gradual building up of the food, but this is likely to 
be only transitory and to end fatally. 

Other charts of von Pirquet which are not given 
here, show equally well the diminished tolerance to 
food caused by febrile disease or excessive heat, with 
the rapid increase in tolerance on a subsidence of the 
fever, as well as the advantage often to be gained by 
giving foods of a higher tolerance limit, such as 
breast milk, in place of cow's milk. 



CHAPTER XX 

ELIMINATION OF BOTTLE FEEDING 

Between the eighth and twelfth months there may 
be added to the ten a. m. feeding two onnces of cereal, 
fed with a spoon. This cereal should at first be 
strained, preferably the cereal that has been used for 
diluting the milk, only made thicker. In addition, 
whether the teeth have appeared or not, a piece of 
rusk or hard bread may be added for the child to 
chew. It is desirable that rusk should be given at 
this time, because it teaches the child to chew, and it 
is the only food that can be given for this purpose, 
because if it is swallowed without chewing it will do 
no harm. It is useful not only in encouraging chew- 
ing, but in stimulating the gastric juice, and in de- 
veloping the jaws, and it undoubtedly assists the 
eruption of the teeth through the mucous membrane. 
The rusks are better than other forms of bread be- 
cause they are hard and not sweetened. In some 
cases pulled bread, toast or zweibach may be sub- 
stituted. This should be given only at the feeding 
time and not between feedings. 

At two f. m., in addition to the bottle and rusk, the 
baby may be given two ounces of clear soup. This 
may be a consomme, mutton broth, or chicken broth, 
which after cooking has been allowed to cool and has 

204 



ELIMINATION OF BOTTLE FEEDING 205 

had all the fat removed. These soups should contain 
a little salt, but no pepper. Later a vegetable soup 
may be given, care being taken that the vegetables 
are thoroughly cooked until soft, and that it contains 
no tomato. 

At six p. m. the same feeding may be used as at ten 

A. M. 

Beef juice. — Beef juice, which is very popular with 
the laity, is apt to be suggested by the parents, under 
the supposition that it is a valuable food. In Figure 

FIGURE 54. 

ANALYSES OF BEEF JUICE OBTAINED BY 

PROCESS 1, AND PROCESS 2, AND OF 

BEEF BROTH 

Beef juice Beef juice Beef broth 

Process 1 Process 2 

Protein 2.90 3.00 1.02 

Fat 60 0.00 

Extractives 3.40 1.90 1.82 

Salts 20 .20 .88 

Water 92.90 94.90 96.28 



100.00 100.00 100.00 

BEEF JUICE 

Process 1. — Lean beef, boil slightly, squeeze in a meat 
press or lemon squeezer. Two ounces of beef juice are ob- 
tained from one pound of beef. 

Process 2. — One pound of chopped meat; 8 ounces of 
water. Put meat with the water in a refrigerator and 
allow it to remain 6 to 12 hours. Then squeeze through 
coarse muslin. Six ounces of beef juice are obtained from 
one pound of beef. 



206 ELEMENTS OF PEDIATRICS 

54 a comparison between the analyses of beef juice 
and beef broth is presented. 

The beef juice may be prepared, as it usually is, in 
a meat press, when about two ounces of juice may be 
extracted from one pound of meat. The analysis 
shows that such meat juice contains much less nour- 
ishment than an equal amount of skim milk, contain- 
ing less than three per cent, protein, and little more 
than % of 1 per cent. fat. It, however, contains 
nearly 3% per cent, extractives, which are not con- 
sidered a food but a tonic. If the beef juice is pre- 
pared as it is in the bacteriological laboratory, by 
allowing chopped meat to stand in a refrigerator 
with water for a number of hours, the resultant juice 
is somewhat less palatable but more juice (about six 
ounces to a pound of meat) may be obtained. Such 
meat juice contains quite as much protein as the 
other but less than 2 per cent, extractives. 

Beef broth. — A beef broth, on the other hand, made 
from soup stock, contains more than 1 per cent, pro- 
tein and nearly the same amount of extractives as 
the juice obtained under the last mentioned pro- 
cess. 

Moreover, if one uses beef juice it should be steril- 
ised by heat before it is fed to a child. Cattle that 
are condemned on account of tuberculosis, if the le- 
sion is not widespread, are used for meat, and babies 
are very susceptible to tuberculosis. On this ac- 
count no raw meat juice should be fed to any baby. 
For all practical purposes then soup replaces beef 
juice. It is more economical, much safer than raw 



ELIMINATION OF BOTTLE FEEDING 207 

meat juice and does not usually have to be espe- 
cially prepared for the baby. 

Vegetables. — At the beginning of the second year 
vegetables may be given in addition to the soup — 
potato, mashed or baked; stewed squash, lettuce, or 
celery, or puree of peas or beans. A rounded table- 
spoonful of one vegetable may be given at first and 
later the same amount of a second vegetable. 

Eggs. — An egg may then be added, preferably soft 
boiled. As eggs occasionally cause a severe anaphy- 
laxis, a minute portion — the size of a French pea — of 
the white of an egg, may be given, and if this causes 
no reaction, the following day half an egg, and the 
third day a whole egg may be given. The reaction of 
children to eggs is peculiar. Some children exhibit a 
severe anaphylaxis, vomiting with convulsions, rash 
and oedema ; others simply vomit N eggs, while still 
other children refuse to take them. In any event it 
is well to accustom the child to the use of egg, and 
this can be done by feeding small quantities at first, 
and even in cases of severe anaphylaxis, minute 
quantities insufficient to produce a reaction should be 
fed daily, increasing gradually, but keeping as far 
as possible within the amount that causes reaction. 
If any reaction occurs, a smaller amount may be 
given. The egg should at first be given at the two 
o'clock feeding, but may later be transferred to the 
breakfast, meat taking its place at the midday meal. 

Meat. — The first meat given a child may be beef or 
lamb, preferably a steak or chop, cooked sufficiently 
to destroy the raw meat colour. The outside is cut 



208 ELEMENTS OF PEDIATRICS 

away and the inside scraped to a pulp with a knife 
blade held at right angles. Of this meat a rounded 
after-dinner coffeespoonful may be fed each day at 
the two o'clock feeding. This amount may be in- 
creased gradually to a teaspoonful or a rounded 
tablespoonful, the latter amount fed once a day being 
sufficient for any child under two years of age. 

Number of feedings. — In the second year it is well 
to eliminate the evening bottle, leaving three meals 
and one feeding of a bottle of milk. 

After the second year, but three meals a day should 
be given. The diet should be mainly farinaceous, 
with a moderate nitrogenous element and moderate 
sugars and fats. Nothing should be given between 
meals excepting water. Such a diet for children of 
three to five years may be as follows : 

Breakfast: Cereal, milk, egg y rusk, toast or crust, 
and one pat of butter. 

Dinner: Soup, four ounces; meat, rounded table- 
spoonful ; two vegetables, one rounded tablespoon- 
ful of each ; and for older children a milk dessert 
with fruit juice over it. 

Supper: Cereal, milk, toast or rusk, small pat of 
butter. 
A glassful of water should be given a half to one 

hour before each meal. 

From the fifth to the tenth year : 

Breakfast: Cereal, milk, one egg y roll and butter. 
Dinner: Soup; meat, equivalent to amount con- 



ELIMINATION OF BOTTLE FEEDING 209 

tained in a French chop ; two heaping tablespoon- 

fuls of vegetables ; milk dessert with fruit juice or 

stewed fruit. 
Supper: Cereal and milk, or milk toast ; toast, hard 

bread or rusk ; one pat of butter. 

A glassful of water should be given a half to one 
hour before each meal. 



CHAPTER XXI 

CAKE OF PREMATURE CHILDREN 

Children born prematurely, especially those of less 
than eight and one-half months of intra-uterine life, 
need special care and the success attained with them 
depends on the methods used. With the best care in 
institutions in France it has been found that the fol- 
lowing results may be obtained. 

An eight month baby weighs about four pounds 
and measures seventeen inches in length, and of 
these about 90 per cent, may be saved. 

A seven month baby weighs about three pounds 
and measures fifteen inches in length, and of these 
50 per cent, may be saved. 

The class of six month babies shows a much greater 
mortality. They weigh only one and one-half 
pounds, are twelve inches long and only 16 per cent, 
of them are saved under the best conditions. 

We may say, then, that there is practically no 
chance of saving a baby of less than six months intra- 
uterine life, or one weighing less than one and one- 
half pounds. After six months of intra-uterine life 
they have some chance, this increasing with the 
longer duration of intra-uterine life. It will be 
noticed by reference to the chart that the gain in 
length is fairly steady from the sixth month, while 

210 



CAEE OF PEEMATURE CHILDREN 211 



the gain in weight increases much more rapidly the 
last month of intra-nterine life. (Figure 55.) 

Premature babies are very inactive, they are apt 
to have a subnormal temperature under ordinary 
room conditions, 
their lungs are not 
well adapted to 
support life by res- 
piration and their 
digestive activity 
is small. The 
proper care of 
these babies in- 
volves, therefore, a 
quiet environment, 
little handling, the 
securing of a nor- 
m a 1 temperature 
by preventing too 
great loss of heat 
from the surface of 

the body, a supply of air of good quality, and correct 
food. 

Incubator. — A proper incubator (Figure 56) is the 
first essential. An incubator is a receptacle supplied 
with moving air, warm enough to keep the baby's 
temperature normal; this is usually somewhere be- 
tween eighty and ninety degrees Fahrenheit. It 
consists of a box with glass windows, and a door with 
an air inlet, preferably from out of doors. It con- 
tains a thermometer for determining the temper- 



Weight and Length of Foetus 

in Utero 
Length A Weight B 


Months 6 7 8 9 


Lbs. 
9 

8 

7 

6 

6 

4 

3 

3 

1 








r 


Ins. 
19 

16 

17 

16 

15 

14 

IS 

12 

11 






j 


/ 






J 








/ 


/* 




/ 




/ 




/ 






/ 




S-* 




A 


,s* 






/ 

















FIGURE 55. 




FIGURE 56. 



Incubator. 
212 



CAEE OF PREMATUEE CHILDREN 213 

ature of the air. The air is heated by passing over 
a receptacle containing water kept at the desired tem- 
perature by a Bunsen burner or kerosene lamp or 
by electric lights. The air is moistened by passing 
over a wet sponge or basin of water. 

Sometimes oxygen may be added at intervals with 
advantage. A little wind-mill at the exit for the air 
is a good indicator of the amount of movement of the 
air. If the wind-mill is whirling rapidly, we know 
that there is sufficient movement in the air. Such an 
incubator shuts out the noises of the room and in 
winter supplies good moving air sufficiently heated to 
preserve normal temperature. The degree of heat 
must be adjusted to the needs of each individual 
child. The child should not be clothed, but wrapped 
in a slight covering of gauze or absorbent cotton in 
such a manner as not to interfere with the movement 
of its legs and arms. 

The indication for the use of an incubator is a sub- 
normal temperature of the child and the child should 
be kept in the incubator until no increase of heat over 
room temperature is necessary to keep the child's 
temperature normal. Boxes or tents are poor sub- 
stitutes for a properly constructed incubator. Espe- 
cial rooms with a temperature of 80° to 85° Fahren- 
heit are used in babies' hospitals where many pre- 
mature babies receive care. 

Feeding of a premature baby. — Premature babies 
are always entitled to breast milk and every effort 
should be made to supply them with it. If they are 
six or seven month babies the breast milk may have 



214 ELEMENTS OE PEDIATEICS 

to be pumped or expressed and modified before feed- 
ing, often a one-half dilution with 3 or 4 per cent, 
sugar of milk added does well. Sometimes pepton- 
ising is an additional help. 

It is usually of advantage to allow the wet nurse to 
nurse her own baby after sufficient milk has been ex- 
pressed to feed the premature baby, for a premature 
baby will not use enough milk to keep the wet nurse's 
breasts active. 

These babies should not be bathed, but may be 
kept sufficiently clean by being washed with soap and 
water when the diaper is soiled. This should be 
done with the least handling possible. 

Although these babies often do remarkably well, it 
should be borne in mind that they are liable to be 
somewhat handicapped in their future development. 



CHAPTER XXII 

MENTAL. DEVELOPMENT OF CHILDREN 

Babies at birth can see and hear, but sight evi- 
dently registers nothing in the brain. They have no 
mental activity. They should be fed and left to 
sleep between feedings. Constant attention and 
handling can put these young babies in a condition of 
acute neurasthenia. One baby of six weeks jumped 
in the crib as I leaned over it. It had been awake all 
night for several nights. By abolishing the devoted 
attention of four grandparents, two parents and two 
trained nurses, leaving the baby alone with one at- 
tendant all day, and giving a warm bath at bed- 
time, all trouble was removed. No attempt should be 
made to amuse young babies. 

At three months they usually begin to recognise 
some person, especially a mother who nurses the 
baby. The cry at this age is characteristic and dif- 
fers entirely from the cry of a six months baby. It 
is not until the ninth to twelfth month that they use 
any words, and then it is usually only mamma or 
papa or no. During the latter part of the second 
year babies should begin to put w T ords together and 
from that time on their vocabulary increases rapidly. 

Instruction. — Systematic attempts to teach these 

215 



216 ELEMENTS OF PEDIATEICS 

young children should be avoided, all means being 
focused on building up a good physique. 

At three years of age, many active children may be 
sent to a proper kindergarten. By proper, I mean 
one that provides a sunny, well ventilated room, and 
is presided over by a woman who has natural ability 
and love for the work, as well as a good education. 
Kindergartens are useful for giving children sys- 
tematic exercise under supervision, for teaching 
them ethics, teaching them to play peaceably with 
other children, and to give and take, and this is the 
first experience many children have in doing any- 
thing but take. Children are also taught observa- 
tion, to differentiate one colour from another, or one 
tree from another, and for this latter purpose classes 
in parks are especially useful. 

Little children have no ability for prolonged con- 
centration, in fact, this is true until early adult life, 
and is one of the reasons why schools, with their long 
sessions, make very slow progress. A child at three 
years should not have more than an hour a day at 
school. A child of six, no more than two hours a 
day, and a child of ten, no more than three hours a 
day, and after each half hour there should be a period 
of five or ten minutes of active exercise. No school 
day should exceed five hours and should include half 
hourly recesses, during which all children are com- 
pelled to exercise. All schools ought primarily to be 
under the care of physicians, who should know the 
children intimately and regulate their study and ex- 



MENTAL DEVELOPMENT 



217 



ercise. Schools should be institutions for physical 
as well as mental development of the child, and the 
physical development should be considered of more 
importance than the mental development. 



CHAPTEB XXIII 

THE MOEAL DEVELOPMENT AND CONTEOL OP 
CHILDEEN 

It is a safe assumption that all healthy children are 
born good, and if they are really bad children it is 
the fault of the parents, just as a balky horse is the 
result of bad management. As an exception to this 
rule there are some children born of alcoholic or 
syphilitic parents who have nervous derangements, 
as may children who have suffered from a cerebral 
hemorrhage at birth or a meningitis. A normal 
child needs only kind, firm control with plenty of 
good suggestion to become a model child. Under 
these conditions an active child will remain an active 
child and an indolent child will be less active but both 
should be tractable and happy. When suggestion is 
wisely used other means are seldom necessary in 
controlling children. 

Suggestion. — Suggestion is less applicable to chil- 
dren under a year of age but often the suggestion 
of a bowl under the buttocks and the flexing of the 
thighs on the body will cause them to strain so as to 
avoid the suppository which they have learned will 
be used if necessary to procure a movement of the 
bowels. 

Control. — Children should never be threatened; 

218 






MOEAL DEVELOPMENT 219 

they should never be deceived or told a falsehood. 
They are easily frightened. Ghost stories and 
stories of horrors should never be told them. They 
should, so long as possible, be considered good 
children and encouraged to live up to that reputa- 
tion. If they are called bad children the reflection 
is usually on the parent not on the child. When 
suggestion fails, the best means of control are re- 
wards and deprivations. Nothing is more appre- 
ciated by healthy young children than food and the 
withdrawing of desserts, if emphasised, is apt to be 
remembered. Rewards also of toys that are much 
desired are apt to secure co-operation but this pre- 
cludes the giving to children of many toys whether 
they behave well or not. 

Corporal punishment is rarely needed; most chil- 
dren if wisely managed never need it. If adminis- 
tered it should never be done in anger but only after 
mature deliberation. 

The telling of falsehoods by young children should 
not be considered the offence it might be in older 
children. Young children do not differentiate well 
between fact and fancy. They are highly imagina- 
tive. One distracted mother said of her boy of six 
years : i ' and the worst of it is he lies when there is 
no object in lying, when there is nothing to be gained 
by it," the best evidence that it was not really a 
serious offence in a boy of that age or an indication 
of a really bad character. 

Many young children show a great deal of grit and 
determination and do what they believe they should 



220 ELEMENTS OF PEDIATRICS 

do with great mental distress without a word of 
complaint. A sturdy little boy on being sent to 
school for the first time made no complaint but every 
week-day morning for the first two weeks vomited 
his breakfast on the way to school. He never 
vomited any other meal nor did he vomit at all on 
Saturday or Sunday. He showed no evidence of any 
ordinary digestive disturbance. 



CHAPTER XXIV 

PHYSICAL EXAMINATION 

In no other department of medicine is a complete 
physical examination, frequently repeated, of such 
importance as in pediatrics. The history obtained 
from parents or attendants should be carefully con- 
sidered as should any information that may be ob- 
tained from the child, but this can never render 
unnecessary a complete examination. Such a com- 
plete examination should be made not only at the 
first visit but at every visit. 

Method of examination. — The following is a gen- 
eral outline of the method of examining infants and 
young children. Space does not allow of a detailed 
description. 

In order that such an examination may be under- 
taken without resistance it is most desirable that the 
child be made friendly to the physician and for 
this purpose the co-operation of the parents and 
nurse is necessary. The child should be taught to 
look on the physician as its best friend and the phy- 
sician while making his examination thorough should 
undertake it in such a manner as to avoid frightening 
the child. The most unpleasant examinations, such 
as the adenoid examination for example, may be 

made without resistance if done sufficiently quickly. 

221 



222 ELEMENTS OF PEDIATRICS 

The physician should obtain the child's confidence by 
kind, sympathetic behaviour and by truthfulness. 
If you once deceive a child you cannot expect any 
further confidence. The desire of the parent to 
awaken a sleeping child on the advent of the physi- 
cian should be forestalled for many valuable obser- 
vations may be made on a sleeping child that are 
impossible when it is awake, especially if frightened. 

Examination while sleeping. — An indication of the 
diagnosis may often be reached by watching a sleep- 
ing child. 

Character of sleep. — Notice the character of the 
sleep whether quiet or disturbed and restless, and 
count the respirations for a full minute because they 
are irregular in infancy and early childhood. 

Respirations; expiratory grunt. — Eapid respira- 
tions if associated with an expiratory grunt and a 
pause at the end of inspiration suggest pneumonia. 

Sunken eyes. — Sunken eyes suggest a lack of fluid 
in the body usually due to diarrhoea or vomiting, or 
both. 

Retraction of head. — If the head is drawn back and 
the legs drawn up one thinks of meningitis. 

Pulse. — The pulse can often be counted if the child 
is sound asleep and it furnishes a diagnostic sign in 
the pulse rapidity and pulse respiration ratio, nor- 
mally one to four but in pneumonia one to three, or 
in the irregular pulse of meningitis. 

Before crying — Abdomen. — Palpation of the abdo- 
men, which should never be omitted, is not satisfac- 
tory if the child is frightened or crying. 



PHYSICAL EXAMINATION 223 

Appendix. — Palpation over the right and left iliac 
region may make or exclude a diagnosis of appen- 
dicitis ; rigidity over the right iliac region being one 
of the best signs. The additional sign of tenderness 
may also be elicited. 

Intussusception. — Any sausage shaped tumour 
found in the abdomen on palpation should suggest 
the diagnosis of intussusception. Fecal impactions 
occur but not commonly in babies. 

Liver. — Enlargement of the liver is common in 
children, a fatty infiltration with enlargement being 
the regular accompaniment of infections in babies. 
Palpation on the left side for enlargement of the 
spleen should be regularly made. A spleen that 
does not come to the free border of the ribs may be 
felt by pressing the hand under the rib during a 
forced inspiration. 

Kidneys. — Deep palpation in the back may disclose 
tenderness over one or both kidneys. 

Abdomen. — Percussion of the abdomen enables one 
to form a judgment of the pressure and location of 
gas in the stomach or intestine. 

Heart. — The heart is another organ that should be 
examined while the child is quiet. Soft blowing 
murmurs cannot be heard under other conditions. 
One should first palpate to locate the apex beat ; per- 
cuss or use auscultatory percussion to form a judg- 
ment of the size of the heart and the location of its 
outline, and then listen to the character of the heart 
sounds and rhythm, bearing in mind that children 
under five years of age are not ordinarily subject to 



224 ELEMENTS OF PEDIATRICS 

rheumatic heart disease, while murmurs due to con- 
genital defect in the heart are not very rare, and that 
murmurs may be hsemic, congenital, inflammatory, or 
due to violent action of the heart from fright. 

After crying. — This part of the examination being 
completed the remainder can be done more easily if 
the child is quiet, but can be carried out even if the 
child fights against it. 

Rachitis. — The chest should be examined for evi- 
dence of rachitis, the rosary, Harrison's groove and 
the contracted thorax with large abdomen, and then 
the examination of the lungs should be undertaken. 

Lungs. — Palpation may first be applied and then 
one should proceed to auscultation as being usually 
much more valuable in locating a lesion than per- 
cussion. Results obtained on examining a sleeping 
child should be confirmed by examination when 
awake. A frail, feeble child may breathe when 
asleep without inflating one lobe of the lungs. Cry- 
ing is a distinct advantage in this examination for 
it provides forced inspiration and voice sounds dur- 
ing expiration and sometimes the only way to get 
voice sounds in babies is to make them cry. Auscul- 
tation should be followed by careful percussion and 
mensuration if indicated. 

Ears. — The ears should next be examined with 
some instrument that the physician is accustomed to 
use, and this examination should never be neglected. 
An instrument with a magnifying lens and a little 
electric lamp in the speculum probably furnishes the 
easiest method of definite diagnosis of ear con- 



PHYSICAL EXAMINATION 225 

ditions by the pediatrist. In little babies with a 
narrow, crooked passage the examination is often 
difficult. The physician should determine whether 
the drum is shiny or dull, white or red, and whether 
the ossicles project in a normal manner or the pos- 
terior segment bulges. In case of doubt or in the 
presence of bulging an ear specialist should be called. 
This examination need not frighten or hurt the child. 
The mastoid region behind the ear should be care- 
fully examined in every case of ear trouble for in- 
flammation, tenderness, oedema or fluctuation. 

Fontanelles. — In children under two years of age 
the four fontanelles should be felt and if the anterior 
fontanelle is open its edges should be mapped out 
and the fingers should be passed over it to determine 
whether there is any bulging due to pressure in the 
cranial cavity. 

Cranio-tabes. — The neighbourhood of the lateral 
fontanelle should be pressed to determine whether 
it denotes the sign called cranio-tabes which is pres- 
ent in many cases of rachitis during the first year 
and sometimes later. 

Stiffness of the back of the neck. — The head may be 
pressed forward to ascertain whether there is any 
resistance in the muscles of the back such as is found 
in certain nervous diseases. 

Nits indicating pediculi may be looked for in the 
hair. 

Glands. — Enlargement of the parotid or submaxil- 
lary glands should be noticed if present, as well as of 
the anterior and posterior cervical lymph nodes. 



226 ELEMENTS 'OF PEDIATRICS 

Eyes. — The eyes should be examined for inflamma- 
tion, discharge or ulceration, and the equality or in- 
equality of the pupils noted as well as their reaction 
to light. 

Nose. — Evidence of inflammation of the nasal 
mucous membrane should be looked for and a one- 
sided inflammation or discharge especially noted, as 
denoting a possible foreign body or sinus trouble. 

Tongue. — The tongue should be carefully examined 
as to the amount of coating, irregular coating, geo- 
graphical tongue, ulceration and moisture. 

Mouth.— In children under eighteen months of age 
the handle of a spoon, or a tongue depressor, that 
has been washed in alcohol may be used for examin- 
ing the mouth just previous to the throat examina- 
tion. Have the child held with the head firm in a 
good light or use a pocket flash light. Examine first 
the gums for irritation of erupting teeth. 

Look for Koplik spots, ulcerations and sprue, and 
then press the back of the tongue down to get a good 
view of the pharynx. In older children the spoon 
may usually be dispensed with except in looking for 
Koplik spots. 

Pharynx. — If children are instructed to open 
their mouths wide, put out their tongues as far as 
possible and then cough hard, a better view of the 
pharynx can usually be obtained than by the use of 
the spoon or tongue depressor. In doing this the 
examiner should be careful to keep his own mouth 
closed in order to avoid infections himself. 

Adenoid. — The adenoid examination can be made 



PHYSICAL EXAMINATION 227 

with little trouble if the examiner is quick. Have the 
child open its month wide, then press the thumb of 
the left hand into the child's cheek so as to force a 
fold of the child's cheek between its molar teeth, 
allowing the fingers of the examiner's left hand to 
make pressure over the left side of the inferior 
maxillary bone. Then the index finger of the right 
hand is quickly passed through the mouth into the 
naso-pharynx where the characteristic soft feel of 
the adenoid is quickly recognised, and in older chil- 
dren a fair estimate of the size of the remaining post- 
nasal space may be made. This method is not safe 
if the child has cut its front teeth but not its back 
teeth. In this case a gag should be used. 

Genitals. — Examination of genitals should be made 
for the presence of discharge and in boys any ad- 
hesions between the glans and the foreskin should 
be separated. This is best done without an instru- 
ment. The examiner, with his hands dry, should 
place one thumb on the glans, the other on the 
foreskin, and then press them apart. This read- 
ily separates adhesions and exposes shut in 
smegma. 

Feet. — In cases of doubtful diagnosis every portion 
of the body should be examined, including the feet 
where a small abscess has sometimes explained an 
obscure fever. 

Kernig — Brudzinski. — In addition to the test for 
stiffness of the back of the neck and the equality re- 
action of the pupils, Kernig's sign and the Brud- 
zinski sign should be looked for. In case of their 



228 ELEMENTS OF PEDIATRICS 

presence a tache cerebral reaction may be looked 
for. 

Measurement. — Measurement of the length of the 
body, the head, chest and abdominal circumferences 
should never be omitted. 

Blood pressure. — Blood pressure determination 
has not been proved to be of sufficient value in chil- 
dren to be included in ordinary examinations. 
Should it be determined a narrow arm band must 
be used. 

This completes the examinations that should or- 
dinarily be made at the bedside. Other examina- 
tions while equally important need special labora- 
tory equipment. 



CHAPTER XXV 

URINARY ANALYSIS 

Of the laboratory examinations the most import- 
ant is the examination of the urine and this to be 
of real value must be much more complete than the 
ordinary routine examinations made in physicians' 
offices or in medical laboratories. 

Obtaining specimen. — A delayed diagnosis is often 
due to difficulty in obtaining a specimen of urine for 
as already stated (page 56) babies make water very 
frequently and a very little at a time. An intelli- 
gent attendant will usually obtain all the specimens 
desired, for infants usually pass water when awake 
and before or during feeding. If a cup is ready 
and placed under a child when it wakes with a dry 
diaper and held there while gentle pressure is made 
above the pubes a specimen of urine can be obtained. 
In male babies all delay may be avoided by inserting 
the penis in a bottle with a large mouth and strap- 
ping the bottle in place with zinc oxide plaster at- 
tached to the abdominal wall. Older children should 
be placed on a chamber and in case they are having 
frequent loose movements from the bowels a sepa- 
rate receptacle must be used for the urine. 

Of the conditions to be looked for in the urine we 
may note in order : 

229 



230 ELEMENTS OF PEDIATKICS 

1. Dilution 

2. Evidences of nephritis 

3. Evidences of diabetes 

4. Evidences of acidity 

5. Evidences of acidosis 

6. Evidences of intestinal intoxication 

7. Evidences of pyelitis 

1. Specific gravity. — The specific gravity of the 
urine gives one information as to the dilution, and 
the solids it contains. A high specific gravity of the 
urine is not uncommon in older children who are not 
naturally thirsty and who thus take little water. 
Such children should be advised to drink water sys- 
tematically between meals. 

2. Nephritis. — Evidences of a real nephritis are 
rarely found in infancy and early childhood. When 
a nephritis is present it is apt to be a sharp attack 
with acute symptoms although a chronic nephritis 
may occur. 

The presence of a small amount of albumin in 
urine during an acute illness is a frequent finding. 

It is occasionally found without acute illness. A 
slight disturbance with the presence of nucleo- 
albumin need not be considered as important as the 
presence of serum albumin. Albumin without casts 
need not lead to serious concern. 

3. Diabetes. — The presence of sugar in the urine is 
very rare, but is found occasionally in cases of diar- 
rhoea. If it is present in considerable quantity and 
is accompanied by other symptoms of diabetes it 
means a very serious disease which until very re- 
cently has been universally fatal. 



UEINARY ANALYSIS 231 

4. Acidity. — Acidity of the urine is a cause of con- 
siderable irritation of the skin in some cases, and as 
an accompaniment is an index of the extent of the de- 
rangement in other conditions, so that a quantitative 
test of the acidity or alkalinity of the urine is very 
valuable in treating these disorders and may easily 
be carried out in accordance with, the methods con- 
sidered later. Acidity is usually readily controlled 
by treatment, while alkalinity of the urine is less 
amenable to drug treatment. 

5. Acidosis. — Several acid bodies appear in the 
urine associated with the condition known as acido- 
sis. Some of these are more readily tested for than 
others, and two that may be detected by simple tests 
and that form a good general index of the condition 
are acetone and diacetic acid. 

Any one making such routine examinations every 
day can soon readily judge of the extent of the pres- 
ence of these bodies by the sharpness of the reaction, 
so that it becomes easy to index the intensity of the 
reaction by using the numbers from 1 to 10 ; number 
1 or 2 indicating a trace ; 4 or 5 a fair amount ; 6 or 7 
a great deal ; and 10 a maximum amount. 

6. Intestinal intoxication. — Another very common 
derangement of young children known as intestinal 
intoxication or intestinal putrefaction gives rise to 
certain products two of which are readily deter- 
mined by simple tests and like the two bodies in aci- 
dosis give a fair indication of certain conditions in 
the bowel; these are indican and phenol, and with 
these as with the acid bodies an index of 1 to 10 is 



232 ELEMENTS OF PEDIATEICS 

fairly accurate. Therefore, in the treatment of this 
condition one can judge of its effects by an increase 
or a diminution in the amount of indican and phenol 
present. 

7. Pyelitis. — Probably the most important finding 
in the urine is the presence of leucocytes, an evidence 
of an inflammatory process in the urinary tract of 
the child. 

The presence of one leucocyte in a high power or 
Zeiss D field in a girl is a normal finding, but the 
presence of this amount in a boy or the presence of 
more than this amount in either a boy or a girl is 
usually an evidence of pyelitis. For the benefit of 
the physician who is treating the case the number of 
leucocytes present should be known. When there 
are only a few, the number in a D field should be 
recorded, but where there is a great deal of pus the 
amount of such precipitate in a test tube is a good 
index. In cases of pyelitis the urine is usually 
pale, colourless, smoky, and of low specific gravity, 
with more or less perceptible precipitate. The bac- 
teria present are for the most part motile bacilli 
easily detected by a Zeiss D lens. 

8. Blood. — The presence of blood in the urine is 
most important in diagnosis. If in an infant it ap- 
pears with no other abnormality scurvy should im- 
mediately be suspected. If it is an accompaniment 
of nephritis other evidences of this disease may be 
present, or it may be found in an active pyelitis. 

The methods of making the tests that have been 
alluded to are as follows : 



UEINARY ANALYSIS 233 

General appearance. — This includes examination of 
the sediment and supernatent fluid. 

The fluid is generally amber or straw col- 
oured. 

It may be entirely colourless or of a deep yellow 
bile colour, or red from blood or amorphous 
urates. 

It is generally clear. A turbid urine usually indi- 
cates amorphous urates or phosphates; a 
smoky urine bacteria. 

The sediment may be brick red from amorphous 
urates, red from blood cells, white from pus or 
phosphates, crystalline from uric acid or other 
crystals. 
Reaction. — Acid — turns blue litmus paper red. 

Alkaline — turns red litmus paper blue. 
Quantitative acidity. — For this determination one 
needs : 

10 c.c. of urine. 

1 drop of 0.5 per cent, phenolphthalein in 50 per 
cent, alcohol. 

1 burette filled with decinormal sodium hydrate 
solution. 

Shake up the urine with about 10 grams of potas- 
sium oxalate crystals. 

Add one drop of phenolphthalein solution, and 
place in evaporating dish. 

Eead level of solution in burette. 

Allow sodium hydrate solution to flow, drop by 
drop, into the evaporating dish until the urine 
is pink. 



234 ELEMENTS OF PEDIATKICS 

Eead burette. The difference between this read- 
ing and the first one indicates the acidity of 10 
c.c. of urine expressed in centimeters of deci- 
normal sodium hydrate solution. Thus, if the 
first reading is 18.7 and the second 21.5, the dif- 
ference is 2.8 for 10 c.c. of urine, which would be 
.28 for 1 c.c. A normal acidity is about 6 c.c. for 
10 c.c. of urine. 
Specific gravity. — May be obtained with an urinome- 
ter. 

As specimens from children are apt to be scanty 
in amount a small urinometer and a one-inch 
urine glass will be of advantage. 
Albumin. — 

Heat and acetic acid test: 

Fill a narrow test tube three-quarters full of urine. 
If turbid, filter. 

Add a few drops of 2 per cent, acetic acid. 

Boil top of urine. 

A cloud seen against a black background indicates 
albumin. The density of the cloud is an indica- 
tion of the amount of albumin. 

When albumin is present in large amounts, a 
rough estimate of the amount in terms of per- 
centage may be made as follows: 

Boil 10 c.c. of urine that has been acidified by 
acetic acid. 

Place this in a graduated centrifuge tube and 
rotate rapidly for two minutes. 

A reading of the percentage of albumin at the bot- 
tom of the tube may then be made. 



UEINAEY ANALYSIS 235 

Cold nitric acid test: 

Over 3-5 c.c. of concentrated nitric acid in a test 
tube place, by means of a pipette, about 10 c.c. 
of urine. 

A white line at the junction of these two fluids in- 
dicates serum albumin. A white cloud above 
the line of junction indicates nucleo albumin. 
Glucose. — 

Fehling's test: Mix 2 c.c. each of Fehling's alka- 
line 1 and copper 2 solutions in a test tube. 

Dilute this with 10 c.c. of water, and boil. 

Add 1 to 2 c.c. of urine. 

Heat to a boiling point and allow to stand at least 
ten minutes. 

A gradually forming red colour or a precipitate 
generally indicates sugar. 

Benedict's solution. 

To 5 c.c. of Benedict's solution 3 in a test tube 

Acid 8 to 10 drops of urine. 

Boil three minutes. 

Allow to cool spontaneously. 

A precipitate of greenish, yellow or red tinge fill- 
ing the entire solution indicates sugar. If the 

i Fehling's Alkaline solution : 

346 grams of sodium and potassium tartrate. 

100 grams of sodium hydrate. Water up to 1000 c.c. 

2 Fehling's Copper solution : 

69% grams of crystalline copper sulphate. 
Water up to 1000 c.c. 

3 Benedict's solution : 

Copper sulphate crystals, 17%0 g rams ; 

Sodium citrate, 173 grams; 

Sodium carbonate crystals, 200 grams; 

Water up to 1000 c.c. 



236 ELEMENTS OF PEDIATEICS 

solution is clear on cooling or shows only a 
slight blue turbidity sugar is absent. 

Fermentation. 

If reduction takes place in the above tests the fer- 
mentation test should be used, in order to ex- 
clude reducing substances other than glucose. 

Shake up in urine a piece of baker's yeast the size 
of a pea until it is in suspension. With this 
mixture fill a fermentation glass and place in a 
thermostat, where it should be allowed to remain 
for at least twelve hours. An accumulation of 
gas in the closed arm indicates the presence of 
sugar. The amount of gas varies with the 
amount of sugar in the specimen. 
Acetone. — 

To 5 c.c. of urine in a test tube of small calibre 

Add two to four drops of a freshly prepared 
aqueous solution of sodium nitro prusside 
(strength about 1 per cent.). 

Add one drop of glacial acetic acid. 

Place over this mixture by means of a pipette 5 c.c. 
of 10 per cent, ammonium hydrate solution. 

Allow this to stand for 1rve minutes. 

A red ring at the line of the junction indicates 
acetone. The more acetone there is present the 
denser will be the ring. 1 
Diacetic acid. — 

To 10 c.c. of urine in a test tube 

i For purposes of recording the result of this and the three follow- 
ing tests, the author uses a scale of 1 to 10. A faint reaction being 
designated as 1, and the most marked reaction possible as 10. 



UEINAEY ANALYSIS 237 

Add 10 per cent, aqueous ferric chloride solution, 
drop by drop. 

If a precipitate forms, filter and add a few more 
drops of ferric chloride solution. 

A Burgundy red colour indicates the presence of 
diacetic acid. 

This test is also positive in the presence of salicy- 
lates, but if the urine is boiled in an open dish 
for five minutes the diacetic acid will be de- 
stroyed, while the salicylates will still give the 
test. 
Indican. — 

Pour into a test tube 5 c.c. of urine. 

5 c.c. of Obermayer's reagent. 1 

2 c.c. of chloroform. 

Place a cork in the open end of the test tube and 
invert tube fifteen times. 

Allow to stand ten minutes. 

A blue colour in the chloroform, which falls to the 
bottom of the tube denotes indican. 

A purple colour indicates potassium iodide. 
Phenol. — 

Boil 5 c.c. of Millon's reagent 2 in a test tube. 

Add a distillate of urine, drop by drop, shaking 

i Obermayer's reagent : 

Ferric chloride 2 grams; 
Concentrated hydrochloric acid 1 litre. 
Dissolve ferric chloride in the hydrochloric acid. 

2 Millon's reagent : 

Warm one part of mercury with two parts nitric acid until the 
mercury is fully dissolved. To each volume of this solution 
of mercuric nitrate add two volumes of distilled water. 



238 ELEMENTS OF PEDIATEICS 

between each until the colour ceases to deepen, 
or a precipitate begins to form. 

A red colour in the fluid indicates phenol. 
Microscopic. — This examination should be made on a 
glass slide, employing high and low powers of 
the microscope. 

The urine is examined for the following : 
Casts. — Not often found in children and usually of 
the hyaline variety. 

Granular casts or other varieties may be found. 
Blood cells. — Eed blood cells are recognised by the 
uniformity of their size, absence of nucleus, and 
crenation when the latter is present. Eed blood 
cells are not a frequent finding. 

White blood cells are found fairly frequently. 

It is of the greatest importance to recognise the 
number of these and whether they are clumped 
so as to form pus. 

If few are present, the average number in a high 
power field may be recorded. 

If much pus is present, the percentage may be 
determined by agitating the specimen so that the 
pus is uniformly distributed. A portion is 
placed in a graduated centrifuge tube and ro- 
tated rapidly for about two minutes. The per- 
centage may then be read. 
Bacteria. — These are easily seen with a high power 

lens, — usually motile bacilli. 
Epithelial cells. — These are of two types, squamous 
and round celled. 



URINARY ANALYSIS 239 

Urates. — Found in acid urine, — amorphous brick red 
urates and uric acid crystals. 

Calcium oxalate crystals. — These are rare in very 
young babies — occasionally found in older chil- 
dren after they have eaten certain fruits and 
vegetables containing oxalates. 

Ammonium urates. — Rarely found in children. 

Triple phosphate crystals and amorphous phosphates 
are found in alkaline and neutral urines. 

Mucus. — Strings of mucus are found in almost all 
specimens. 

Recording the test. — The record of the test should 
appear as follows: 

Date : Name : 

Appearance : 
Reaction : 
Sp. Gr. 
Albumin : 
Glucose : 
Acetone : 
Diacetic acid: 
Indican : 
Phenol : 
Microscopic : 



CHAPTER XXVI 

EXAMINATION OF THE FECES 

Of all the clinical pathology of the diseases of 
children, the subject of feces is probably the most 
neglected and unexplored. It is, however, full of 
interest and promise. There are two ways of ap- 
proaching this study, the chemical and the clinical. 
By chemical, I mean the exact pains and time taking 
work that is done by a chemist in a complete chemi- 
cal laboratory. By clinical, I mean the more rapid 
and relative and less exact means that can be per- 
formed by any physician in his laboratory. These 
latter methods give valuable information to the phy- 
sician and with them this chapter will deal. 

Obtaining specimens. — Feces for examination 
should be obtained without the aid of cathartic or 
enema, and free from urine, if possible, as varying 
amounts of water make the findings less accurate. 
The amount should be at least equivalent to one 
heaping tablespoonful. To obviate the unpleasant 
and adherent odour, it is well' for the observer to 
wear a gown over the clothing and work under a hood 
or in the draught of an electric fan. 

Colour. — The colour, consistency, odour and re- 
action should first be determined. The normal stool 

240 



EXAMINATION OF THE FECES 241 

varies in colour from yellow to brown, depending 
somewhat upon the age and diet of the child. Grey 
stools generally suggest undigested food material or 
mucus; green stools undigested protein; clay-col- 
oured stools stoppage or absence of bile and the 
presence of undigested fat ; and black or tarry stools 
the presence of bismuth, iron or old blood. 

Consistency. — The consistency is usually either 
solid, semi-solid, liquid, or liquid with hard masses. 
Bits of undigested food of varying sort, curds of un- 
digested protein or soaps of undigested fat may be 
present. 

Odour. — The odour of a normal stool is often only 
mildly offensive. A putrid odour suggests protein 
indigestion and autointoxication. A sour stool 
points to carbohydrate fermentation. This may be 
very irritating to the skin of a diaper baby. 

Reaction. — The reaction of normal feces is gen- 
erally faintly acid. Strong acidity points to carbo- 
hydrate fermentation, and strong alkalinity to pro- 
tein indigestion. 

Microscopic examination. — Under the microscope 
the feces should be examined for meat fibres, vege- 
table spirals, seeds, hard fruit particles, ova and 
parasites. 

The relative number of bacteria and their type 
present in stools is of interest. A thin smear prep- 
aration may be fixed on a glass slide by passing it 
nine times rather rapidly through a flame in a 
horizontal direction. The preparation is stained by 
the Gram method and counter-stained. Large num- 



242 ELEMENTS OF PEDIATRICS 

bers of Gram negative bacilli are generally found. 
Gram negative cocci may also be present. Large 
numbers of Gram positive organisms are found in 
the feces of children suffering from the Intestinal 
Infantilism of Herter. These may be bifurcated 
bacilli, square ended or pointed bacilli or micro- 
cocci. 

Undigested food. — For the pediatrist a knowledge 
of the undigested food present in the feces is of con- 
siderable importance. 

In the case of fat in the feces we look with the 
naked eye for fatty curds and we examine micros- 
copically for fat droplets. The microscopical exam- 
ination for fat is unsatisfactory, as only a very 
small portion of the stool is examined. A smear of 
the stool is made and stained under a cover glass 
with Sudan III. 1 This stains all the neutral fats. 
The droplets can be counted under a high power 
lens. There should be in a normal stool not more 
than twelve droplets of fat to a slide. 

A drop of glacial acetic acid is then run under the 
cover glass and gentle heat applied until the prep- 
aration begins to bubble. This changes the soap to 
fatty acids, which then take the stain. There should 
be not more than six droplets in a high power field in 
a normal specimen. 

For protein determination, three methods are 
open to the observer. Macro scopically the specimen 
is examined for casein curds; microscopically it is 

i Sudan III. Sudan III, 0.3 gram ; 70 per cent. Ethyl alcohol 
100 c.c. 



EXAMINATION OF THE FECES 243 

examined for meat fibres; and lastly the Schmidt 
test, described below, may be applied. 

To find undigested starch, we may examine a 
smear stained with Lugol's solution. 1 After stain- 




FIGURE 57. 
Apparatus foe Schmidt's Fermentation Test. 

ing, the smear is washed for an instant in tap water 
and examined with the microscope for blue starch 
particles. In a normal stool there should be no 
starch present. 

i Lugol's Solution. Iodine, 1 part ; Iodide of Potassium, 2 parts ; 
Water, 17 parts. 



244 ELEMENTS OF PEDIATKICS 

Schmidt fermentation test: A standard amount 
of feces, such as 10-15 grams or a teaspoonful, taken 
from the more solid part of the specimen is shaken 
up with warm water until the material is evenly 
liquified. An apparatus designed for this purpose 
(Figure 57) is completely filled with the fluid and 
left in a thermostat at a temperature of 35 to 37° C. 
for three days, a reading being recorded each day. 
Carbohydrate ferments the first and second days, 
and the gas evolved by this fermentation rises to 
the top of the cylinder. The amount of gas gives 
an indication of the relative amount of undigested 
carbohydrate. At this time, if there is carbohy- 
drate fermentation the specimen should have an acid 
reaction. 1 The protein decomposes on the third day 
and if this takes place more gas rises in the tube and 
the reaction of the specimen becomes alkaline. 

i The reaction may be tested by pressing down the glass rod and 
so forcing out through the tube on to a piece of litmus paper a drop 
of the contents of the cylinder. 



CHAPTEE XXVII 

EXAMINATION BY ROENTGEN-RAY 

In many cases valuable evidence for diagnosis may 
be obtained by Boentgen-Ray examination, and this 
is more readily accomplished in the case of children 
than adults, for children are easily moved, and this 
may be done without injury even when they are 
fairly sick. 

The use of the Roentgen-Bay in determining in- 
jury to bones has long been evident but its value in 
ascertaining changes in the cavities of the body is 
only now becoming appreciated. In intra-thoracic 
diseases it is particularly valuable. In cases of 
acute miliary tuberculosis it gives one a typical pic- 
ture when physical signs may be wanting, and the 
same is true of pneumonia. Pneumonia that pre- 
sents no physical signs may be discovered by Roent- 
gen-Ray and even when the location of the consolida- 
tion is thus made evident it may be impossible to 
elicit any physical signs. 

The Roentgen-Ray is valuable in differentiating 
consolidated lung from fluid, while in pneumo-thorax 
it gives a definite picture of the condition. 

Again in endocarditis we obtain not only evidence 
of the condition but definite information, better than 
can be obtained by percussion, of the enlargement of 

245 



246 ELEMENTS OF PEDIATEICS 

the heart and the damage to it ; while in pericarditis 
the Roentgen-Ray will differentiate between plastic 
exudate and fluid. 

In abdominal disease it is of less value, for in some 
evident conditions, such as certain tumours, it gives 
little shadow; it, however, shows well the distribu- 
tion of gas in the intestines, the presence and location 
of obstruction and the existence of ulcers in the 
stomach and duodenum. Cases of ptosis or abnor- 
malities of the colon or sigmoid flexure are well por- 
trayed by this method. 

In hospital work, examination by Roentgen-Ray 
has become almost a routine procedure for diagnosis, 
prognosis and a control of treatment, but in private 
practice it has still not attained the use to which it 
is entitled. 



CHAPTER XXVIII 

DIAGNOSIS 



Only a brief sketch can be made here of the gen- 
eral method of reaching a diagnosis of the common 
illnesses of infancy and early childhood. 

Diagnosis in infancy and early childhood must be 
based primarily on physical examination and rarely 
does an experienced pediatrist have difficulty in 
reaching a definite diagnosis. 

Figure 58 illustrates a method of judging in diag- 
nosis The history and temperature record show 
whether the disease is probably in the afebrile or 
febrile class, while if in the latter class the rapidity 
ot the respirations gives one a clue to further sub- 
division. Rapid respirations, that is, respirations 
over torty, suggest an involvement of the lungs No 
matter how much confidence a physician has in his 
nurse he should take the pulse and respirations him- 
selt. It the respirations are not persistently accel- 
erated, the diagnosis is more apt to fall in the last 
class, m which the diseases are arranged in order of 
tJieir frequency. 

«. Th !A X P J 6SSi0n ° f the Cbild ' flusLed or P^e cheeks, 
the attitude, retraction of the head, flexion of the 
legs the active motion of the alae nasi, the type of 
breathing, whether the pause is at the end of expira- 



248 



ELEMENTS OF PEDIATRICS 



tion, as in normal breathing, or at the end of in- 
spiration, as in pneumonic breathing, should all be 
noted as these factors aid in arriving at a diagnosis. 
One should always bear in mind the two condi- 
tions most apt to be over-looked on account of too 
superficial an examination: a pyelitis, the diagnosis 

Figure 58. 
DIAGNOSIS CHART 



Afebbile 



Febeile 



Rapid Respirations 



modebate nobmal 
Respirations 



("Tuberculous Meningitis 
■1 Certain Blood Diseases 
[Chronic Diseases 

Bronchitis 

Pneumonia 

Acute Pulmonary Tuberculosis 

Empyema 

Pneumo-thorax 

Cardiac Disease 

Gastrointestinal Disorder 

Pharyngitis 

Tonsillitis 

Otitis Media 

Dentition 

Acute Contagious Diseases, 
Measles, Scarlet Fever, Diph- 
theria, Mumps, Chicken-pox 

Meningitis 

Pyelitis 

Rheumatic Disease 

Typhoid Fever 

Malaria 

Intestinal Worms 



of which can only be made after a urinalysis, and an 
otitis, which often in infants gives no indication of 
its presence and is only discovered by careful exam- 
ination of the ear drum. 



DIAGNOSIS 249 

Under afebrile conditions there is noticed tuber- 
culous meningitis. Although some rise of temper- 
ature may exist, this temperature is rarely much 
above normal. Also in diseases of the blood, some 
of these, such as a simple anaemia, may have no rise 
of temperature, while with Hodgkin's Disease, leuke- 
mia, or von Jaksch's Disease, a rise of temperature 
may exist. In most chronic diseases fever plays lit- 
tle part. 

Of febrile diseases with rapid respirations we note 
different conditions of the lungs and heart, but it 
should also be remembered that conditions in the 
abdomen that force the diaphragm up or cause great 
pain may produce some dyspnoea. Also in pneu- 
monia there may be only slight acceleration of res- 
pirations if the pneumonia is not accompanied by 
bronchitis, and the same is true of pulmonary tuber- 
culosis. In empyema the rapidity of respirations 
is somewhat proportionate to the amount of fluid 
present, just as in pneumothorax the respira- 
tions are proportionate to the amount of air pres- 
ent. 

Of those febrile disturbances, with moderate or 
normal respirations, we may note that an acute ill- 
ness with fever is most apt to be a stomach disturb- 
ance associated with a coated tongue or nausea or 
vomiting or constipation or diarrhoea. With such 
disturbances, chills and a very high temperature 
may occur. 

Influenza often causes a fairly high remitting tem- 
perature for a number of days and while generally 



250 ELEMENTS OF PEDIATBICS 

associated with local signs these may be entirely 
lacking. 

Otitis media, usually a complication of a cold or 
influenza, should always be kept in mind and looked 
for in every child who is sick, even if it has rapid 
respirations or is afebrile, for this is a most uncer- 
tain, deceptive and often very dangerous compli- 
cation. Ears that are bulging and filled with pus 
and require immediate puncture of the drum, will at 
times give no evidence of pain or tenderness in 
babies. 

A diagnosis of dentition is allowable if the child 
has swollen red gums and little else to find, after a 
careful, thorough physical examination. 

The acute contagious diseases which most children 
must have in order to gain an immunity should be 
borne in mind, especially in children over a year old. 
These diseases begin mostly with symptoms in the 
upper air passages : measles, scarlet fever, German 
measles, mumps, chicken-pox, meningococcus menin- 
gitis, acute poliomyelitis. 

The Pons asinorum of pediatrics is pyelitis. 
Eunning an irregular temperature with marked re- 
missions lasting a day or two, it produces an irreg- 
ular temperature chart on which in many cases a 
presumption of the diagnosis can be made. This can 
only be confirmed by a microscopic examination of 
the urine, which shows many pus cells and bacteria. 

In children over five years of age, rheumatic dis- 
ease should be borne in mind, the only evidence often 
at the beginning of the disease in children being a 



DIAGNOSIS 251 

soft, blowing murmur over the heart. Any child in 
whom a physical examination reveals nothing but an 
increasing temperature and a developing soft blow- 
ing murmur over the apex of the heart should be 
given the benefit of anti-rheumatic treatment. 

Typhoid fever and malaria are both very rare now 
in young children in well regulated communities, and 
the diagnosis should only be positively made when 
confirmed by blood examinations or other scientific 
tests. 

Intestinal worms should be borne in mind as occa- 
sionally causing severe prostration with fever in sus- 
ceptible children. 



CHAPTER XXIX 

TKEATMENT 

The treatment of children should consist much 
more in the general management of the case than in 
the administration of drugs, for, as a general rule, 
babies tolerate drugs poorly. 

Fever. — All children with fever should imme- 
diately be put to bed in a well ventilated, sunny and 
quiet room. The bowels should be moved by an effi- 
cient purgative and, if indicated, the bowels should 
be washed. If the fever is high, baths at 100° Fah- 
renheit for ten minutes, followed by hve minutes at 
85° or 90° F. should be used. The diet should con- 
sist of plenty of water, clear soups and gruels. On 
the prompt institution of these precautions the rapid 
recovery of many cases depends. The drug treat- 
ment that is adopted in addition to this will depend 
on the result of the physical examination and urin- 
ary analysis. 

Method of administering drugs. — In giving drugs 
to babies, they must be administered in solution, sus- 
pension, or as powders moistened, for babies cannot 
swallow tablets or pills. In babies under one year 
of age, drugs with flavours most repulsive to adults 
will be taken with apparent relish. Thus asafoetida, 
which has a flavour most objectionable to adults, is 

252 



TBEATMENT 253 

taken well by babies and is often most valuable in 
the control of colic. Castor oil also is usually taken 
well by babies and is, perhaps, the most valuable of 
all drugs in the treatment of babies under one year 
of age. In children more than a year old, care must 
be taken to administer drugs in as acceptable a form 
as possible, but one should not hesitate to give 
quinine or salicylate of soda if indicated, for if given 
with sufficient syrup, most children will take them 
with little objection. 

These drugs are best given in an undiluted com- 
pound syrup of sarsaparilla or syrup of Yerba 
Santa. Quinine is best given as the bisulphate, a 
soluble salt, in the proportion of two grains to the 
drachm. 

Dose. — The proportion of the adult dose to be 
given children of different ages may be estimated by 
either Young's or Cowling's formulae, remembering 
that some drugs are much more poorly tolerated by 
children than others, and that these formulae are only 
a rough estimate. 

Young's formula states that the dose equals the 
age divided by the age plus twelve : 

Age 
Dose = Age + 12. 

This gives the dose at different ages as the follow- 
ing proportions of the adult dose, 

1 year i/ 13 

2 years y 7 

4 years % 

12 years y 2 



254 ELEMENTS OF PEDIATKICS 

Cowling's formula states that the dose should be 
the age at the next birthday divided by twenty-four. 
This gives the dose as follows : 

_^ Age at next birthday 

Dose = — — 

24 

1 year y 12 

2 years % 

5 years % 

11 years % 

Of strychnine, babies over a year old can take a 
comparatively large dose, while to belladonna and 
opium and coal tar derivatives they are very suscep- 
tible. 

Tablets or pills may be administered dissolved in 
water or syrup in a teaspoon. If the medicine is 
ordered in fluid form in syrup it is well often to 
give it in a smaller dose than a teaspoonful. For 
these fractions of a teaspoon two measures are con- 
venient : one squeeze of a medicine dropper bulb will 
usually give about fifteen drops, or a quarter tea- 
spoonful, while an after-dinner coffeespoon holds 
thirty drops or half teaspoonful. 

In using spoons as measures it must be remem- 
bered that it is possible to pile liquid in a spoon and 
thus measure much more than a drachm in a tea- 
spoon. Thus one may say that 

One medicine dropperful = y S2 oz. 

Two medicine dropperfuls = 1 coffeespoonful = y 16 oz. 

Two coffeespoonfuls = 1 teaspoonful — y 8 oz. 

Two teaspoonfuls — 1 dessertspoonful = % oz. 

Two dessertspoonfuls — 1 tablespoonful = y 2 oz. 

These are convenient but rough inaccurate measurements. 



TREATMENT 255 

The vehicle used is usually water with one-eighth 
part glycerine or one quarter part syrup. This may 
be a simple syrup or orange syrup, or if it is desired 
to cover a strong or bitter flavour the compound 
syrup of sarsaparilla or the syrup of Yerba Santa. 

In older children of four to six years cachets are 
well taken, while in children over six years of age 
pills may usually be administered. 

Therapeutic measures. — A very brief summary of 
some of the most useful measures for fulfilling 
clinical indications for treatment are indicated be- 
low. 

To empty the alimentary tract and move the 
bowels quickly, especially where the contents are 
suspected of causing trouble, no other drug is as 
useful as castor oil. It should be given alone during 
the first year, but later may be given with orange 
juice, a second glass of orange juice without oil being 
given immediately after, or syrup or some other 
agent to cover the taste of it. If the parents state 
that the child cannot take it, the doctor should ad- 
minister it himself, giving the child no notice of what 
is coming until he is ready to administer it, then 
pour it rapidly into the mouth from a spoon, press 
the lips together and have the face toward the 
ceiling. It will then flow into the throat and be 
swallowed. Should the first dose be vomited, a sec- 
ond dose will usually be retained, if given half an 
hour later. 

A dose of ten drops of castor oil is usually suffi- 
cient during the first month, while by the end of the 



256 ELEMENTS OF PEDIATRICS 

first year two drachms are usually required and at 
two years a tablespoonful. 

Possibly the most useful internal treatment in 
diarrhoea in infancy is the administration of castor 
oil in doses of one or two drops with each feeding. 
In older children these small doses may be given in 
mucilage and sarsaparilla, which completely disguise 
the taste. Proprietary substitutes for castor oil 
have seemed to me to have no advantages. 

Calomel stands next to castor oil in the treatment 
of intestinal infections and may often have some ad- 
vantage over castor oil where a severe lung compli- 
cation exists or is feared. This is best given in 
tablet triturate dissolved in warm water in a tea- 
spoon. The dose in babies under one year is usually 
one-tenth grain repeated every hour or half hour, 
until the bowels act or one grain is given. When 
severe symptoms exist in children over six months 
old, the whole dose may be given at once. 

In chronic constipation, which is most apt to be 
troublesome at the end of the first year in children 
who are inactive and have not been put on a mixed 
diet, milk of magnesia is perhaps most useful, or 
rhubarb or cascara. Exercise and coarse foods are 
the most important curative agents. In the latter 
class, oatmeal, graham bread and bran biscuits are 
efficient. Alkalis are most important in the treat- 
ment of the digestive disturbances of children, espe- 
cially if associated with the odour of acetone in the 
breath and a marked acidity of the urine with the 
presence of acetone and diacetic acid in the urine. 



TKEATMENT 257 

Bicarbonate of soda may be given in solution in 
one-fourth orange syrup and water in doses of two 
to ten grains every hour until the urine is rendered 
alkaline. 

Milk of magnesia being strongly alkaline is a good 
laxative to give in association with this treatment. 

Intestinal putrefaction characterised by foul 
breath, abdominal distention and offensive move- 
ments with indican and phenol in the urine is best 
treated by laxatives, especially rhubarb, as well as 
lacto-bacillary culture and bowel washings. 

Tonics are little indicated in early childhood. 
Nux vomica is perhaps the best appetizer given in 
doses of one-half to two minims three times a day, 
while in cases of anaemia the syrup of the iodide of 
iron in doses of three to ten minims three times a 
day after meals is most useful. 

Sedatives, on the other hand, are much more fre- 
quently indicated. Quiet is the most important 
sedative for babies. Warm baths at 100 degrees 
Fahrenheit continued for twenty minutes are most 
efficient. Very small amounts (% 6 grain) of gum 
asafcetida in solution is most efficient in babies under 
three months. Next in order are bromide and 
chloral, sometimes of use in convulsions, and last, 
opium, rarely indicated, which may be given in the 
form of paregoric in three or five minim doses in 
babies under a year, or morphine sulphate by hypo- 
dermic in Vwo or % grain doses in a child under a 
year. 

Cough syrups should rarely be given babies, as 



258 ELEMENTS OF P^DIATEICS 

they are apt to upset them. A safe and efficient 
application for pharyngeal coughs is a solution of 
tincture of the chloride of iron. This may be given 
as early as the third month in a solution containing 
one scruple to one-half ounce of glycerine and water 
to four ounces; Of this, a coffeespoonful may be 
given every hour when the child is awake. Older 
children will take a stronger solution up to one 
drachm to the same amount of glycerine and water. 
For persistent and disturbing cough at night, a mix- 
ture of tincture of belladonna one-half drachm, wine 
of ipecac, one-half drachm, and paregoric, three to 
five minims in syrup and water, may be given every 
three hours p.r.n. 

Mustard plasters or capsicum vaseline over throat 
or chest relieve cough and in chronic catarrhal in- 
flammation cod liver oil is a valuable remedy. 

Antipyretics do young children much harm when 
administered as they are in adults. The legitimate, 
harmless, valuable antipyretics are cool air circu- 
lating about the body and warm baths at 100 degrees 
Fahrenheit, followed by five minutes at 85 degrees or 
90 degrees Fahrenheit. Cold baths and ice packs 
are resented by babies and are rarely needed. Coal 
tar antipyretics should never be given to young 
children. 

Heart stimulants are rarely required by young 
children except in extreme conditions. Strychnine 
in doses of Koo grain may be used in babies a year 
old. Digitalis is often useful but must usually be 
given in large doses to obtain a definite effect. I 



TEEATMENT 259 

have given repeatedly an adult dose of the tincture 
(ten drops) to a child of six years, with no effect on 
the pulse. One should always begin with a small 
dose of two or three drops and increase gradually. 
Digitalin is sometimes of more use and digipuratum 
sometimes gives excellent results. 

Antirheumatics are the same for children as for 
adults and when needed are often well taken. Chil- 
dren of six or eight years often require ten grains of 
sodium salicylate every two hours to control rheu- 
matic symptoms, or aspirin in the same dose. 

Atophan, grains 7/->, night and morning, is often 
more efficient and less disturbing. 

Methods of medication. Stomach. — Drugs are ad- 
ministered to children usually by the stomach and if 
apt to upset the stomach they are given after feed- 
ing, so that they become part of a very considerable 
volume of food and are thus well dissolved and ab- 
sorbed more slowly. Tonics to stimulate appetite 
and laxatives are more efficient often if taken on an 
empty stomach. 

Rectal medication. — Rectal medication may be 
used for nauseating drugs in infancy. Thus in per- 
sistent convulsions, bromide and chloral are usually 
given in solution by rectum. In acidosis with per- 
sistent vomiting alkalis are often introduced by 
means of an alkaline enema. In dysentery, starch 
is often valuable if injected in solution after a bowel 
washing. Suppositories of glycerine or gluten are 
often valuable in constipation. 

Skin. — a. The skin may be used for absorbing 



260 ELEMENTS OF PEDIATEICS 

drugs. Thus in syphilis in babies a blue ointment 
diluted one-half is an excellent method of medication. 
In emaciated children with dry skin, cod liver oil 
inunctions are believed to be valuable. 

b. Counter-irritation of the skin is often valuable. 

Hot water or ice bags produce a useful local hyper- 
emia. Mustard pastes are most valuable, made with 
ground flaxseed one part in six to one part in two. 
A mixture of equal parts turpentine and olive oil is 
an excellent liniment for babies. 

c. Scarification, as in vaccination or von Pirquet 
test. 

d. Hypodermic medication as in the introduction 
of antitoxin or typhoid or other vaccine inoculation. 

e. Intravenous medication is sometimes used when 
very prompt action is needed. 

Inhalation. — The most valuable inhalation for all 
children is good, fresh, cool out of door air for 
twenty-four hours each day. Oxygen is an excellent 
stimulant in babies too young for the usual stimu- 
lation by stomach. 

Steam or creosote inhalations are useful occa- 
sionally, but they involve usually a hot, close room, 
which deprives the child of the cold, fresh air, which 
gives it resistance. 

In conclusion : Babies should have little medicine 
and unless there is some specific medication avail- 
able it is well to resort to those simple methods 
which enable the body to resist infections and are 
harmless. Coal tar derivatives should be given with 
caution. 



INDEX 



Abdomen, 10 

protruding, 1 

at birth, variability in meas- 
urement of, 6 

circumference of, 6 

prominence of, in infants, 10 

at birth, 65 

examination of, 222 

palpation of, 223 

percussion of, 223 

tumor of, 223 
Abdominal binder, 07 

conditions, Roentgen ray in 
diagnosis of, 246 

distention, 257 
Abnormalities of breast milk, 

130-131 
Accessory feedings, 131, 141 
Acetic acid test for albumin in 

urine, 234 
Acetone, 231 

in urine, test for, 236 

in breath, 256 
Acidity of urine, 231, 256 

quantitative, 233 

milk of magnesia in, 256 
Acidosis, 231 
Adenoid, 8 

enlargement of, 8 

necessity for removal of, 8 

seat of, 37 

hypertrophy of, 39 

a cause of enuresis, 89 

examination may be made 
without resistance, 221 

examination, method of mak- 
ing, 226 
Adhesions of foreskin, 96, 227 
Adipose tissue, 5 
Adult skull compared to that of 

infant at birth, 35 
Afebrile conditions, 248 

261 



Age at which girls are heavier 
than boys, 27 
at which boys are heavier than 

girls, 27 
at which boys are taller than 

girls, 30 
at which girls are taller than 

boys, 30 
feeding of child in regard to, 

165 
a factor in caloric needs, 177 
Air in nursery, fresh, 76 
fresh, 92 

fresh air in house, 92 
roof extensions for securing 

fresh, 92 
benefit derived from change of, 

93 
change of, 93 

swallowed during feeding, 133 
out of door, a stimulant, 260 
Alae nasi in diagnosis, 247 
Albumin, acid, 13 
Albumin in urine, 230 

in urine, tests for, 234 
Albuminose, 13 
Alexins according to Von Beh- 

ring, 170 
Alimentary tract, contamination 
of by bacteria, 51 
emptying of, 255 
Alkaline laxative, milk of mag- 
nesia, 257 
Alkalis in digestive disturbances, 

256 
Alveolar process, development 

of, at birth, 8 
Amino acids, splitting up of pep- 
tones into, 50 
Ammonium urates in urine, 239 
Amorphous phosphates in urine, 
233 



262 



INDEX 



Amorphous urates in urine, 233 
Amusing the baby, 82 

toys for, 83 
Amylolytic action of secretion of 

pancreas, 13 
Amylolytic ferment, 170 
Analysis of breast milk, 123 

of milk, value of, 127 

of barley water, 185 
Anaphylaxis, eggs a cause of, 

207 
Anatomy of the new born, 1. 
Anemia, simple, 249 

treatment of, 257 
Anorexia during dentition, 43 
Antipyretics, 258 
Antirheumatics, 259 
Antitoxin, 260 
Anuria, 73 

method of overcoming, 73 
Anus at birth, 65 
Aorta, 2 

descending, 2 
Apparatus for modification of 
milk, 165 

for Schmidt fermentation test, 
243 
Appearance of infant at birth, 5 

of urine, 233 
Appendages of foetal heart, 4 
Appendix, position of, at birth, 
11 

vermiform, 50 

vermiform, situation of, 50 

examination, 223 
Arch of foot, broken, 95 
Argyrol, use of in eyes, 65, 74 
Arrangement of nursery, 78 
Arteries, carotid, 2 

pulmonary, 2 

subclavian, 2 

umbilical, 2 
Arteriosus, ductus, 2 
Artificial feeding, 144 

methods of, 176 
Asafoetida, 252 

as a sedative, 257 
Aspirin, 259 
Atophan, 259 
Auricle of heart, left, 2 



Auricle of heart — Continued. 
right, 2 
opening between, 4 

Auscultation of lungs, 224 

Auscultatory percussion of heart, 
223 

Austria-Hungary, infant mortal- 
ity in, 58 

Austrian laws regarding toys, 
84 

Babcock test, 126 

Babies, new born, 12 

feeding of those who do not 

thrive, 183 
susceptibility of to tubercu- 
losis, 206 
care of premature, 211 
inactivity of premature, 211 
incubator for premature, 211 
feeding of premature, 213 
cleansing of premature, 214 
wet nurse for premature, 214 
time when they begin to rec- 
ognise people, 215 
amusing of, 215 
at birth, sight and hearing of, 

215 
(See also Infants) 

Baby jumper, 93 

Bacillus typhosis. Thermal 
death point of, 169 
Bulgaricus, 190 

Bacteria. Usefulness of, 51 
present in breast milk, 128 
in milk, 148 
thermal death-point of, in a 

moist medium, 169 
of feces, 241 

Bacteria, Intestinal, 51 
experiments on, 51 
bacillus acidophilous, 52 
bacillus bifidus, 52 
bacillus coli communis, 52 
bacillus lactis aerogenes, 52 
bacillus perfringans, 52 

Bacteria in milk, 147 

contamination with, 147 
method of avoiding, 148 
killed by pasteurisation, 168 



INDEX 



263 



Bacteria in urine, 238 

in pyelitis, 232 
Bactericidal action. Effect of 

heat on, 170 
Bad children fault of parents, 

218 
Balanitis, 96 
Barley water, 185 

analysis of, 185 
Barns, for cows, 146 

certified milk. Washing facil- 
ities in, 148 
Bath, the, 89 

arrangements for, 90 

contraindications to, 90 

method of bathing, 90 

temperature of, 90 

for fever, 252 

as a sedative. Warm, 257 

as an antipyretic. Warm, 258 
Bath tub. Convenient, 89 
Bathing of baby at birth, 66 
Bean cereal, 186 
Bed-wetting, 88 

cause of, 89 

control of, 89 
Beef, 207 

from tuberculous cattle, 206 
Beef broth. Analysis of, 205 

preparation of, 206 
Beef juice, 205 

analyses of, 205 

methods of preparing, 205 

amount of nourishment in, 
206 
Belladonna, the use of in enure- 
sis, 89 

dose of, 254 

tincture of, 258 
Benedict's test for glucose in 

urine, 235 
Bicarbonate of soda, 257 
Bile, excretion of in intrauter- 
ine life, 13 

action in digestion, 50 

when secreted, 50 

clay coloured stools an indi- 
cation of insufficient, 86 
Bile salts, secretion of in in- 
tra-uterine life, 13 



Binder, abdominal, 67 

Birth, peculiarities of child at, 1 

a critical moment, 4 

changes in infant at, 4 

colour of child at, 5 

sebaceous glands at, 5 

cerebral hemorrhage at, 100 
Bismuth a cause of dark stools, 

86 
Bladder, ligaments of, 4 

at birth, 10 

an abdominal organ at birth, 
10 

control of, 88 
Blindness due to ophthalmia, 65 
Blood, placental, 2 

supply of foetus, 2 

vessels supplying foetus, 2 

at birth, 13 

corpuscles, number at birth, 
14 

hemoglobin in, 14 

hemoglobin at birth. 14 

fresh, a cause of red stain in 
feces, 86 

old, a cause of dark stools, 86 

in urine, significance of, 232 

cells in urine, 238 
Blood pressure, 228 
Bones, of skull, ossification of, 34 

Roentgen ray in diagnosis of 
injury to, 245 
Boracic acid solution, 64 
Bottle, emergency, 141 

sanitary nursing, 166 

position of during feeding, 176 

feeding, elimination of, 204 

elimination of evening, 208 
Bovaird, Doctor, 46 
Bowels, securing movement of, 
218 

cleansing of in case of fever, 
252 

measures for moving, 255 

(See also intestines) 
Boys, age at which they are 
heavier than girls, 27 

age at which they are taller 
than girls, 30 
Brain, size of at birth, 7 



264 



INDEX 



Brain — Continued. 

slight protection of at birth, 7 

development of, at birth, 8 

growth of, 37 

weight of, 37 

weight chart of, 38 
Branchiogenic clefts, 65 
Bread, pulled, 204 
Breast feeding, weight results of, 
22 

mortality in, 60 

possible for most mothers, 
120 

inadequate, 127 

position for baby in, 132 

air swallowed during, 133 

position after, 133 

sleepy infant at, 133 
Breast milk, percentage of fat, 
sugar, and protein in, 70 

analyses of, 71, 123 

percentage of water in, 71 

salts in, 71 

table of percentage of ingredi- 
ents in, 71 

in poverty, 118 

superiority of, 118 

contra-indications to use of, 
119 

curds of, 119 

protein of, 119 

reasons for superiority of, 119 

determination of quantity of, 
121 

necessary quantity of, 121 

method of obtaining speci- 
mens of, 122 

quality of, 122 

caseinogen in, 123 

fat in, 123 

protein in, 123 

sugar in, 123 

Holt's test for, 124 

Dr. Holt's apparatus for ex- 
amination of, 124 

salts in, 124 

specific gravity of, 124 

Babcock test for fat in, 126 

chemical analysis of, 127 

inadequate, 127 



Breast milk — Continued. 
value of analysis of, 127 
bacteria of, 128 
not a sterile food, 128 
effect of exercise on, 129 
effect of worry, shock and fa- 
tigue on, 129 
abnormalities of, 130-131 
treatment of abnormalities of, 

130-131 
accessory feedings, 131 
correction of deficiency in, 142 
variation in secretion at dif- 
ferent times of day, 142 
cow's milk a substitute for, 

144 
higher tolerance limit of, 203 

Breast, secretion of in first days, 
70 
stimulation of secretion by 
nursing, 141 

Breathing of infants, difficult, 4 
insufficient, 4 
type of, 247 

Breck feeding tube, 72 

Bromides, 257 

Bronchi, 9 

Broth, beef, 205 

Brudzinski's sign, 227 

Bulgaricus bacillus, 190 

Bulging of ear drums, 250 

Bunion, cause of, 96 

Buttermilk in infant feeding, 190 

Cachets, 255 
Caecum at birth, 10 
Caecum, 50 

inflammation of, 50 
situation of, 50 
Calcium oxalate crystals in 

urine, 239 
Calcium phosphate in cow's 

milk. 152 
Calendar, use of in enuresis, 89 
Calomel, 256 

dose of, 256 
Caloric requirements, estimation 
of, 176 
needs at different ages, 177 
values of different elements of 
food, 177 



INDEX 



265 






Cane sugar, 193 
Canopies over crib, 78 
Capsicum vaseline, 258 
Carbohydrates, caloric value of, 

177 
Carbonate of potash, used to 
neutralise malt extract, 192 
Care of infant during first day, 
63 

during second day, 73 
Carotid arteries, 2 
Caseinogen in breast milk, 123 

in cow's milk, 153 

separation of, 187 
Castor oil, 253-255 

dose of, 255 

substitutes for, 256 
Casts in urine, 238 
Catarrhal inflammation, 258 
Cattle, tuberculosis of, 206 
Cereal, 204 

bean, 186 

flour, 185 
Cereal diluents, 154-184 

food value of, 185 

method of preparing, 185 
Cerebral hemorrhage at birth, ef- 
fect of, 100 
Certified milk, 144 

commission, Dr. Coit's orig- 
inal, 145 

barns, equipment of, 148 
Cervical lymph nodes, 225 
Changes in the heart after birth, 
4 

in infant at birth, 4 
Chapin dipper, 162 
Characteristics of infant, 1 
Charts, weight, 15 

normal weight of first week of 
life, 17 

normal weight of first year, 18 

individual weight, 20-21 

weight, variation in average, 
22 

average weight of first year, 
23 

with normal weight line, 24 

average weight from birth to 
twelfth year, 25 



Charts — Continued. 

average weight and height of 

boys and girls from birth to 

sixteen years, 26 
showing that loss of weight is 

an important indication of 

approaching illness, 28 
average height during first 

year of 120 well cared for 

children, 29 
length of children of the same 

weight at different ages, 31 
head and chest circumference 

at different ages, 33 
showing increase in weight of 

certain organs during in- 
fancy and childhood, 38 
showing deaths by months in 

New York, 59 
temperature during pasteur- 
isation of a bottle of milk 

at 10°C. and one at 17°C, 

174 
Von Pirquet, 198, 199, 200, 

201, 202 
weight and length of foetus in 

utero, 211 
Cheese-cloth screens, 77 
Chemical analysis of breast milk, 

127 
Chest circumference, 32 

at different ages, chart of, 33 
Chewing, encouragement of, 204 
Chicken-pox, 250 
Child in utero, nourishment of, 

1 
Children, older, average gain in 

weight of, 24 
school, average weight of 69,- 

000, 26 
orphan asylum, average weight 

of, 26 
proper exercise for, 95 
eye-minded, 100 
defective, 100 
dull, 100 
feeding of at different ages, 

165 
reaction of to modification of 

amount of food, 199 



266 



INDEX 



Children — Continued. 

premature, 210 

age at which, they first use 
words, 215 

at birth, mental activity of, 
215 

mental development of, 215 

instruction of, 215 

age at which children may at- 
tend kindergarten, 216 

bad, 218 

born good, 218 

moral development and con- 
trol of, 218 

suggestion in control of, 218 

frightening of, 219 

imagination of, 219 

rewards and deprivations in 
control of, 219 

should be made friendly to 
physician, 221 

physical examination of, 221 

confidence of, 222 

deceiving of, 222 

emaciated, 260 
Chloral, 257 
Circulation, foetal, 2 
Circumcision, 96 

of female children, 97 
Circumference of abdomen, 6 
Clean milk, 145 

essentials for production of 
146 
Cleft palate, 65 

interference of in nursing, 119 
Clitoris, adhesions around, 96 
Clock for nursery, 79 
Clothing, danger of too tight, 66 

binder, 67 

time for discarding binder, 67 

diaper, 67 

danger of too much bed, 68 

dress, 68 

for night, 68 

petticoat, 68 

proper, 68 

shirt, 68 

too warm, 68 

wet, 68 

all babies wear, 69 



Clothing — Continued. 

babies should wear, 69 

of individual child, 70 

insulation by, 70 
Coal tar, derivatives, 254, 260 

antipyretics, 258 
Coit, Dr. Henry L., 145 
Coli communis bacillus. Ther- 
mal death point of, 169 
Colic, 133 

effect of feeding whey milk on, 
188 

asafcetida in, 253 
Colostrum, 70 

percentage of fat, sugar and 
protein in, 70 

analysis of, 71 

coagulation of, 71 . 

microscopic examination of, 
71 

percentage of water in, 71 

purgative action of, 71 

salts in, 71 

table snowing amount of in- 
gredients in, 71 

on second day, 74 
Colour of infant at birth, 5 

of urine, 233 

of feces, 240 
Column, spinal, 7 
Commission, certified milk, 145 
Concentration, lack of ability for 

in children, 216 
Condensed milk, proportion of 
elements in, 193-194 

in infant feeding, 193 
Confidence of child toward phy- 
sician, 222 
Congenital defect, 63 

of heart, 63 
Conjunctivitis, 73 
Consistency of feces, 241 
Constipation, fat in food a pre- 
ventative, 87 

control of by kindergarten ex- 
ercises, 99 

in underfed children, 128 

chronic, 256 

exercise in, 256 

milk of magnesia in, 256 



INDEX 



267 



Constitution, lymphatic, 9 
Contagion, 97 
Contagious diseases, 250 
Contamination of vaccination, 

112 
Control of children, 218 
Convalescence, weight a guide in, 

27 
Convulsions due to eggs, 207 

treatment of, 257 
Cool air as an antipyretic, 258 
Cord, umbilical, 2, 4 

fibrous, 4 

cutting of the, 64 
Cornmeal, 185 
Corns, cause of, 96 
Corporal punishment, 219 
Corpuscles, red blood, number at 
birth, 14 

white blood, number at birth, 
14 
Cough, syrups, 257 

treatment for, 258 
Coughing at night, treatment 

for, 258 
Counter-irritation of skin, 260 
Cows, proper barns for, 146 

clipping of udders and sides, 
146 

grooming of, 146 

tail, clipping of, 146 

washing of, 146 

contamination of udder of, 149 

tuberculosis of, 150 
Cow's milk, a substitute for 
breast milk, 144 

composition of, 151, 153 

mineral matter in, 152 

protein of, 152 

dilution of, 154 

modification of, 154 
Cowling's formula of dose of 
drugs for children, 253, 254 
Cramps, treatment for, 83 
Cranial cavity pressure in, 225 
Cranio-tabes, 7, 225 
Crawling, period at which chil- 
dren begin, 94 
Cream, in milk modifications, 
162 



Cream — Continued. 

gravity, 163 
Creosote inhalations, 260 
Cretinism, 101 

delayed dentition in, 43 
Crib, canopies over, 78 
construction of, 78 
position of in nursery, 78 
quilted hangings for, 78 
Cry of baby, character of, 215 
Crying, examination before, 222 
Crystals in urine, 239 
Cummings, method for modifica- 
tion of milk used by Doctor, 
154 
Curds, in feces, composition of, 
86 
in feces, due to indigestion, 86 
in feces, 242 

an evidence of protein indiges- 
tion, 86 
of breast milk, 118 
of cow's milk, 152 
effect of cereal diluents on, 

184 
composition of, 186 
in stools, effect of peptonising 

on, 186 
size of, in cow's and mother's 
milk, 187 
Curves of spine, normal, 36 
Cyanosis, 64 

Damp days, 92 
Dangers to milk, 148 
Dangerous articles used for toys, 

83-84 
Day, regime for, 102 
Deafness, 100 
Deceiving children, 219 

result of, 222 
Defecation on second day, 73 
Defective children, 100 
Dentition, 39 

age at which first tooth ap- 
pears, 39 

development of first, 39 

late, 39 

age of eruption of teeth, 40 

figure showing first, 40 



268 



INDEX 



Dentition — Continued. 

summary of, 40 

second, 41 

age of appearance of second 
teeth, 41 

summary of second, 41 

figure indicating age of erup- 
tion of second, 42 

anorexia during, 43 

delayed in cretinism, 43 

delayed in rachitis, 43 

disturbances of, 43 

early in syphilis, 43 

fever during, 43 

Hutchinson's teeth, 43, 

indications of early, 43 

a cause of pharyngitis^ 43 

sore gums in, 43 

symptoms of, 43 

examination of teething child, 
44 

rubbing teeth through gum, 
44 

diagnosis of, 250 
(See also teeth and teething.) 
Determination of children, 219 
Development, 15 

reason why certain parts of 
infant are more developed 
than other parts, 4 

of alveolar process at birth, 8 

of nose at birth, 8 

weight as a standard of, 15 

of first dentition, 39 

of children, mental, 215 

moral, of children, 218 
Dextri-maltose, 192 

Mead's, 192 
Dextrinised cereal, 185 
Diabetes, 230 
Diacetic acid, 231 

test for, in urine, 236 
Diagnosis, 247 

pulse in, 247 

respirations in, 247 

chart, 248 
Diagnostic sign of pulse, 222 
Diaper, 67 

cause of red stains of, 10 

best form of, 67 



Diaper — Con tinned. 
objection to rubber covering 
over, 68 

changing of, 104 
Diaphragm, 10 

development of at birth, 10 

position of at birth, 10 

importance in respiration, 10 

hernia of, 64 
Diaphragmatic respiration, 67 
Diarrhoea, 59 

castor oil in, 256 
Diet, after second year, 208 

fifth to tenth year, 208 

of wet nurse, 140 

in fever, 252 

(See also Feeding.) 
Digestion, 13-46 

part taken by stomach in, 13 

of starch, saliva in, 47 

action of bile in, 50 
Digestive fluid, saliva, 47 
Digestive disturbances, alkalis 

in treatment of, 256 
Digipuratum, 259 
Digitalin, 259 
Digitalis as a heart stimulant, 

258 
Dilution, of cow's milk, 154 

of urine, 230 
Diphtheria, bacilli in milk, 148 

bacillus, thermal death point 
of, 169 
Dipper, Chapin, 162 
Dirt, inhalation of, a cause of 

infection, 97 

Disease of mother not always an 

indication for weaning, 135 

Dose of drugs for children, 253 

Draughts, effect of on children, 

77 
Dress, 68 

Dressing of babies, 66 
Drugs, flavours of, *252 

method of administering, 252 

in solution, 252 

treatment in fever, 252 
Dry milk, 194 

composition of, 194 

method of producing, 194 



INDEX 



269 



Dry milk — Continued. 

method of preparing formulae 
containing, 195 
Ductus, arteriosus, 2 

venosus, 2 

venosus, changes of, 4 

venosus, time of change, 4 
Dull children, 100 

treatment of, 100 
Dura mater, 7 
Dyspnoea, cause of, 249 



Ear-minded children, 100 
Ear-drums, bulging of, 250 
Ears, 9 

development of, at birth, 9 

mastoid cells, 9 

deafness, 100 

examination of, 224 

instrument for examining, 224 

difficulty of examining babies, 
225 

pain in, 250 

pus in, 250 
Eggs, 207 

convulsions due to, 207 

method of first giving, 207 

reaction of children to, 207 
Eiweiss milk, 190 
Elasticity of gastric wall, 48 
Elimination of bottle feeding, 

204 
Emergency feedings, 141 
Encouraging children, 219 
Endocarditis, Roentgen-ray in 

diagnosis of, 245 
England, infant mortality in, 58 
Engle, experiments on micturi- 
tion, 56 
Enuresis, nocturnal, 88 

causes of, 89 

methods for control of, 89 
Epithelial cells in urine, 238 
Establishment of function of 

lungs, 4 
Eustachian valve, 2 

disappearance of, 4 
Examination, of child at birth, 
65 



Examination — Continued. 

at birth, serious results of 

neglect to make, 66 
laboratories for physical, 100 
of school children, 100 
adenoid, 221 
physical, 221 
before crying, 222 
after crying, 224 
of feces, 240 

of feces. Microscopic, 241 
by Roentgen-ray, 245 
Exanthemata, acute, in nursing 

mother, 120 
Exercise, 106 
for children, 93 
baby jumper a means of ob- 
taining, 93 
walking, 94 

proper kind for children, 95 
for constipation, 256 
Experiment for determining 

number of bacteria in milk, 

147 
Expiratory grunt in connection 

with respirations, 222 
Expression of child in diagnosis, 

247 
Extremities, blood supply of 

foetal, 2 
nourishment of, 2 
Eye, at birth, 8, 64 

a perfect organ at birth, 8 
cause of poor perception at 

birth, 8 
lachrymal glands at birth, 8 
care of at birth, 64 
ophthalmia, 65 
conjunctivitis of, 73 
examination of on second day, 

73 
use of argyrol in, 74 
use of silver nitrate in, 74 
washing of with boracic acid 

solution, 74 
minded children, 100 
sunken, cause of, 222 
examination of, 226 

Face, small, 1 



270 INDEX 


Face — Continued. 


Feces — Continued 


at birth, 7, 33 


dark colour due to old blood, 


at birth, size of, 8 


86 


increase in size of, 33 


dark colour due to iron, 86 


reason for increase in size of, 


fresh blood a cause of red stain 


34 


in, 86 


Failure to gain, 24 


mucus in, 86 


Falsehoods, telling of by chil- 


respiratory mucus in, 86 


dren, 219 


shininess of, 86 


Fatigue, 95 


smoothness of, 86 


effect of, on breast milk, 129 


frequency of movement of, 87 


a cause of inadequate breast 


softness of, 87 


milk, 143 


odour of, 87, 241 


Fats, absorption of in intestines, 


quantity of normal, 87 


50 


method of obtaining movement 


action of pancreatic secretion 


of, 88 


on, 50 


loose, 128 


in breast milk, 70 


offensive, effect of buttermilk 


in colostrum, 70 


on, 190 


in food, clay coloured stools 


effect of malt on, 193 


an indication of too much, 


impactions of, 223 


86 


colour of, 240 


in feces a cause of shiny char- 


examination of, 240 


acter, 86 


obtaining specimens of, 240 


excess of in food, 87 


bacteria of, 241 


in breast milk, 123 


consistency of, 241 


in breast milk, Babcock's test 


microscopic examination of, 


for, 126 


241 


too much in breast milk, 142 


reaction of, 241 


deficiency of in breast milk, 


protein in, 242 


142 


test for undigested food in, 


in cow's milk, 151 


242 


content of a quart bottle of 


undigested food in, 242 


milk, 162 


Schmidt fermentation test, 


percentage of in quart bottle 


243 


of milk, 163 


(See also Stools) 


splitting ferment, 170 


Feeding, improper, a cause of 


caloric value of, 177 


failure to gain, 24 


indigestion, evidences of, 180 


during first twenty-four hours, 


Febrile conditions, 248 


70 


Feces, passed in first days, 72 


tube, Breck, 72 


on second day, 73 


breast, interval of on second 


normal appearance of, 85 


day, 74 


colour of normal, 85 


on second day, 74 


quality of, 85 


time at which change is made 


colour of abnormal, 85-86 


to four hour interval, 104 


curds in, 86, 242 


during first year, 117 


dark colour due to bismuth, 86 


different methods of, 118 


clay coloured, an indication of 


breast, inadequate. 127 


too little bile, 86 


accessory, 131, 141 



INDEX 



271 



Feeding — Continued. 

method of breast, 132 

emergency, 141 

mixed, 141 

artificial, 144 

infant, 144 

modification of milk for in- 
fant, 154 

normal, 155 

malt in infant, 156 

cream modifications in infant, 
163 

for babies of different ages, 
165 

methods of artificial, 176 

amount of time that should be 
taken over, 176 

average of a baby during the 
first year, 177 

for the first year, 178 

changes in amount of labora- 
tory, 181 

amount of first, 181 

of difficult cases, 183 

buttermilk in infant, 190 

maltose in infant, 192 

malt soup in infant, 192 

theory of infant, 197 

over-, 198 

after second year. 208 

of premature baby, 213 

modification of breast milk 
for premature babies, 214 
Feedings, number of, 208 
"Feedings that fit," 195 
Feet at birth, 65 
Feet, 95 

the care of the, 95 

examination of, 227 
Fehling's test for glucose in 

urine, 235 
Femora, effect on, by diaper, 67 
Fence, nursery, 94 
Fermentation test, for glucose in 
urine, 236 

of feces, 243 

Schmidt's, 243 
Ferments of milk, 168 

effect of heat on, 170 
Fever, inanition, 18 



Fever — Continued. 

during dentition, 43 

treatment of, 252 
Finklestein milk, 190 

preparation of, 191 

substitute for, 191 

uses of, 191 
Fireplace as a means of ventila- 
tion, 76 
First year feeding, 117 

examples of, 178 
Flat foot, cause of, 95 
Fleischner, Doctor, 30 
Flour, cereal, 185 
Foetal, circulation, 2 

appendages of heart, useful- 
ness of, 4 
Foetus, blood vessels supplying, 
2 

heart of, 2 

in utero, 211 

in utero, weight and length of, 
211 
Fontanelles, 6 

anterior, 6, 34 

lateral, 6, 7 

posterior, 6 

size of at birth, 6 

anterior, bulging of, 34 

anterior, importance in diag- 
nosis, 34 

closing of, 34 

figure showing, 35 

at birth, 65 

examination of, 225 
Food, passage of into intestines, 
13 

spoiling of by heat, 60 

mortality in infants fed on 
artificial, 60 

first artificial, 72 

clay coloured stools an indi- 
cation of too much fat in, 86 

excess of fat in, 87 

time at which character of 
food is changed, 105 

choice of in first year, 117 

conditions that govern choice 
of, 117 

value of cereal diluents, 185 



272 



INDEX 



Food — Continued. 
proprietary, 195 
administration of, 197 
maximum amount of, 197 
minimum amount of, 197 
optimum amount of, 198 
tolerance of, 198 
reaction of child to modifica- 
tion of amount of, 199 
effect of reducing to a mini- 
mum when the tolerance is 
only slightly reduced, 200 
effect of temporary with- 
drawal of when tolerance is 
considerably reduced, 201 
effect of withdrawal of when 
tolerance is of or below the 
minimum, 202 
first food to be added after 

bottle, 204 
undigested as shown in feces, 

242 
coarse food in treatment of 
constipation, 256 
Foot, flat, cause of, 95 
Foramen ovale, 2, 4 
closing of, 4 
patent, 64 
Foreskin, adhesions of, 96, 227 

retraction of, 96 
Formula, defective, a cause of 
loose stools, 87 
preparation of, 156-161 
for malt soup, 193 
containing dry milk, 195 
France, infant mortality in, 58 
Frequency of movements^ 87 
Fresh air, 92 
in nursery, 76 
rest in, 91 

not a cause of illness, 97 
Frightening of children, 219 
Frontal bone, orbital plate of, 8 
Function of lungs, establishment 

of, 4 
Furniture for nursery, 78, 79 

Gain in weight, failure to, 24 
in spite of bad stools, 132 
Games, 95 



Gas in intestines, effect of but- 
termilk on, 190 
Gastric, wall, elasticity of, 48 

capacity, measurement of, 49 

juice, stimulation of, 204 
Genitals, at birth, 65 

retraction of foreskin, 65 

care of, 96 

examination of, 227 
Geographical tongue, 226 
German measles, 250 
Germany, infant mortality in, 58 
Ghost stories, 219 
Girls, age at which they surpass 
boys in weight, 27 

age at which they are taller 
than boys, 30 
Gland, Thymus, 9 

enlargement of, 9 

size of, 9 

weight of, 44 

position of, 44 
Glands, 225 

sebaceous, 5 

sweat, development of at birth, 
5 

salivary, secretion of, 13 

salivary, time of increase of se- 
cretion of, 13 
Glucose, tests for, 235 

in urine, fermentation test 
for, 236 
Goat's milk, 144 

Gonococcus infection of eyes, 65 
Gravity cream, 163 
Graduate, sugar of milk, 165 
Grooming of cows, 146 
Growth, in height, 29 

of special parts of body, 30 

of brain, 37 

in length of spine, 37 

of post-nares, 37 
Gums, sore, due to teething, 43 

Habit, in micturition, 88 

in moving bowels, 88 

masturbation, 96, 97 

thumb sucking, 98 

kissing, 99 
Hands at birth, 65 



INDEX 



273 



Hare lip, 65 

an interference with sucking, 

46 
interference of in nursing, 119 
Head, 7 

of infant, 1 
blood supply to, 2 
proportion of, 5 
circumference of at birth, 6 
size of at birth, 7 
and chest circumference, 32 
circumference, 32 
circumference at different 

ages, chart of, 33 
distortion of at birth, 65 
retraction of, 222, 247 
Heart, foetal, 2 

changes in after birth, 4 
changes in at birth, 4 
opening between auricles of, 4 
structure of in intra-uterine 

life, 4 
at birth, size of, 9 
weight chart of, 38 
increase in weight of, 44 
position of, 45 
congenital defect of, 63 
action at birth, 65 
disease, decayed teeth a cause 

of, 91 
examination of, 223 
sounds, 223 

disease, rheumatic, 224 
murmurs, 224 
stimulants, 258 
Heat, effect of on certain biologic 

characteristics of milk, 170 
Height, 27 

of boys and girls, comparison 

of, 27 
during first year of 120 well 

cared for children, 29 
first year, 29 
growth in, 29 
second year, 29 
importance of record of, 29 
variation between that of 

boys and girls, 30 
of premature babies of differ- 
ent ages, 210 



Hemoglobin, amount of, 14 

Hemorrhage, cerebral at birth, 
100 

Hernia, diaphragmatic, 64 

Herter, intestinal infantilism of, 
242 

Hippius, effect of heat on cer- 
tain biologic characteristics 
of milk as determined by, 
170 

Hodgkins' disease, 249 

Holt, Doctor, 47 

test for breast milk, 129 

Home modification of milk, 181 

Hospital rooms, especially for 
premature babies, 213 

Hot water bag, 260 

Human milk, percentage of in- 
gredients of, 71 
(See also breast milk.) 

Humidity, a cause of infant mor- 
tality, 60 

Hutchinson's teeth, 43 

Hydrocephalic type of idiocy, 100 

Hydrochloric acid, free, 13 

Hygiene of nurse^, 75 

Hyperaemia, 260 

Hypodermic medication, 260 

Ice bags, 260 

ldiocv, hydrocephalic type of, 

ioo 

microcephalic type of, 100 
Mongolian type of, 100 
benefit of treatment of, 101 
cretinism, 101 
Iliac, internal, 4 
Illegitimacy, a cause of infant 

mortality, 60 
Illness, a cause of failure to 
gain, 24 
a cause of inadequate breast 

milk, 143 
on part of mother a contra- 
indication to nursing, 120 
Imagination of children, 219 
Immunisation for typhoid fever, 

115 
Inactivity of premature babies, 
211 



274 



INDEX 



Inanition fever, 18 
Incubator for premature babies, 
211 
illustration of, 212 
air supply of, 213 
heating of, 213 
substitutes for, 213 
Indexing, reaction of urine to 
acetone and diacetic acid, 
231 
pus in urine, 232 
Indican in urine, 231 
in urine, test for, 237 
in intestinal putrefaction, 257 
Indigestion, evidences of, 180 
Infant, characteristics of, 1 
comparison of with adult, 1 
examination of, 1 
head of at birth, 1 
reason for development of cer- 
tain parts of, 4 
at birth, appearance of, 5 
at birth, colour of, 5 
at birth, length of, 6 
at birth, examination of, 65 
body, proportions of compared 

to adult, 5 
absence of intestinal bacteria 

in newly born, 51 
care of the healthy, 57 
the care during the first day 

of the, 63 
dressing of, 66 
first washing of, 66 
newly born, light for, 70 
care of during the second day, 

73 
treatment of during first 

months, 82 
result of attention paid to 

during first year, 85 
exercise for, 93 
indications in, for weaning, 

134 
loss of weight in first few 

days, 121 
of wet nurse, control of, 139 
Infant feeding, 144 

importance of intelligent, 117 
modification of milk for, 154 



Infant Feeding — Continued. 

malt in, 156 

cream modifications in, 163 

cereal diluents in, 184 

buttermilk in, 190 

malt soup in, 192 

maltose in, 192 

graphic representation of, 197 

theory of, 197 
Infant mortality, 57 

in various countries, 57 

causes of, 58 

hot weather in cities a cause 
of, 58 

reduction of, 58 

by months in New York, va- 
riation in, 59 

in artificially fed children, 60 

humidity a cause of, 60 

illegitimacy a cause of, 60 

in summer, 60 

poverty a cause of, 60 

measures for reducing, 61 

in private practice, 61 
Infantilism of Herter, intestinal, 

242 
Infections, navel, direction taken 

by, 5 

navel, 64 

of eyes, 65 

of eyes by gonococcus, 65 

of intestine, 71 

protection from, 97 

methods for prevention of, 98 
Inferior vena cava, 2 
Inflammation of urinary tract, 

232 
Influenza, 249 
Inhalation medication, 260 
Instruction of children, 215 
Instrument for examination of 

ears, 224 
Internal iliac, 4 
Intestinal bacteria, 51 

absence of in new born, 51 

time at which invasion takes 
place, 51 

u^pfnlness of, 51 

bacillus acidophilous, 52 

bacillus bifidus, 52 



INDEX 



275 



Intestinal bacteria — Continued, 

bacillus coli communis, 52 

bacillus lactis aerogenes, 52 

bacillus perfringans, 52 
Intestinal infantilism of Her- 

ter, 242 
Intestinal infection, 71 

a cause of loose stools, 87 
Intestinal, intoxication, 231 

worms, 251 

putrefaction, 257 
Intestines, 49 

at birth, 10 

elastic nature of, 49 

length of, 49 

length of large, 49 

length of small, 49 

absorption from, 50 

growth of, 50 

at birth, sterile, 71 

time for obtaining movement 
from, 85 
Intoxication, intestinal, 231 
Intra-thoracic diseases, Roent- 
gen-ray in, 245 
Intra-uterine life, organs in, 4 

viability of babies with differ- 
ent periods of, 210 
Intravenous medication, 260 
Intraventricular partition, defec- 
tive, 64 
Intussusception, 223 
Inunctions, 260 
Iron, a cause of dark stools, 86 

syrup of the iodide of, 257 

tincture of chloride of, 258 
Italy, infant mortality in, 58 

Jaws, development of, 204 
Juice, beef, 205 
Jumper, baby, 93 

Keller's malt soup, 192 

Kernig's sign, 227 

Kidneys, size of at birth, 10 

weight chart of, 38 

growth of, 46 

increase in weight of, 46 

examination of, 223 



Kindergarten, 99 

proper teacher for, 99 

age at which children may at- 
tend, 216 

benefits of, 216 

proper, 216 
Kissing, 98 

dangers of, 99 
Koplik spots, 226 

Laboratory milk, 162 
Laboratories for modification of 

milk, 155, 182 
Lachrymal glands at birth, 8 
Lactalbumin in cow's milk, 152 
Lactation, inadequate, 142 
Lacto-bacillary, culture, 190 

milk, 190 
Lactose, in breast milk, 123 

in cow's milk, 152 
Lactoserum, 170 
Lamb, 207 

Laws regarding toys, 84 
Laxatives, 257 

milk of magnesia, 257 
Legs, 1 

growth of, 30 

flexion of, 247 
Legume flour, 185 
Length, relation of weight to, 
15 

growth of children who do not 
gain in weight, 30 

of children of the same weight 
at different ages. 31 

of foetus in utero. 211 
Leucocytes in urine. 232 

normal number in urine, 232 
Leukemia, 249 
Ligaments of bladder, 4 
Light in nursery, 77 
Lighting of nursery, artificial, 

78 
Lime water in milk modifica- 
tions, 157 
Liniment, 260 
Liver, 50 
Liver, blood supply of, 2 

nourishment of, 4 

at birth, 10 



276 



INDEX 



Liver — Continued. 

fat of, 10 

size of at birth, 10 

weight chart of, 38 

fatty, 45 

increase in size of, 45 

position of, 45 

enlargement of, 223 

examination of, 223 
Loeffland's malt soup, 193 
Loss of weight in first days, ef- 
forts to avoid, 72 
Lungs, changes in at birth, 4 

establishment of function of, 
4 

in intra-uterine life, 4 

solid organs, 4 

structure of, at birth, 9 

of infant, variation in struc- 
ture from adult type, 9 

weight chart of, 38 

changes in structure of, 45 

growth of, 45 

weight of, 45 

unequal expansion of, 54 

at birth, 63 

palpation of, 224 

physical examination of, 224 
Lymphatic constitution, 9 
Lymph nodes cervical, enlarge- 
ment of, 9, 225 



Macroscopic examination of 

.feces, 242 
Magnesia, milk of, 256 
Malaria, 251 
Malt, 185 

in infant feeding, 156 
extract, use of neutralised, 

192 
soup, 192 

soup formula, 192-193 
effect of on feces, 193 
Maltine, 193 
Maltose, 191 

Maltzyme, neutralised, in the 
preparation of malt soup, 
193 
Mammala, 195 



Marasmus, fresh air an aid in, 

77 
Mastoid, cells, development of at 
birth, 9 

inflammation of, 9 

region, examination of, 225 
Masturbation, 96 

in female babies, 96 
Maximum amount of food, 197 
Mead's dextri-maltose, 192 
Measles, 250 

German, 250 
Measurements, at birth, 6 

chest, 32 

head, 32 

of body, 228 

for doses of medicine, 254 
Meat, from tuberculous cattle, 
206 

first meat to be given a child, 
207 

method of preparing for chil- 
dren, 207 
Meconium, 13, 71 

amount of, 13 

method for expulsion of, 73 
Medication, methods of, 259 

by rectum, 259 

through the skin, 259 

by stomach, 259 

by counter-irritation, 260 

by hypodermic, 260 

by inhalation, 260 

intravenous, 260 

by inunctions, 260 
Meningitis, pulse in, 222 

retraction of head in, 222 

tuberculous, 249 
Meningococcus meningitis, 250 
Menstruation of mother no indi- 
cation for weaning, 135 
Mental development of children, 

215 
Metchnikoff, commendation of 

buttermilk by, 190 
Methods, of supplementing de- 
ficiencies in breast milk, 
142 

of modification of milk, 156 

of artificial feeding, 176 



INDEX 



277 



Methods — Continued. 

of preparing formulae contain- 
ing dry milk, 195 

for care of premature children, 
210 

of making physical examina- 
tion, 221 

of medication, 259 
Microcephalic type of idiocy, 100 
Microscopic examination, of 
urine, 238 

of feces, 241 
Micturition, frequency of, 56 
Milk (see breast milk also), 71 

superiority of breast, 118 

superiority of over other food 
for infants, 118 

reasons for superiority of 
breast, 119 

contra-indications to use of 
breast, 119 

certified, 144 

cow's, a substitute for breast, 
144 

goat's, 144 

clean, 145 

commissions, Dr. Coit's plan 
for, 145 

essentials for production of 
clean, 146 

bacteria in, 147, 148 

contamination of with bac- 
teria, 147 

cooling of, 147 

receptacles, sterilisation of, 
147 

dangers to, 148 

contamination of from bac- 
teria in udder of cow, 149 

typhoid bacilli in, 149 

commission of county of New 
York, 150 

composition of cow's, 151 

dirty water as a source of con- 
tamination of, 149 

fat content of cow's, 153 

dilution of, 157 

fat content of a quart bottle 
of, 162 

preparation of modified, 166 



Milk — Continued. 

sterilisation of, 168 

ferments of, 170 

prescription, 183 

peptonising of, 186-187 

action of rennet on, 187 

Eiweiss, 190 

Finklestein, 190 

lacto-bacillary, 190 

protein, 190 

maltose in, 192 

condensed, in infant feeding, 
193 

dry, 194 

composition of dry, 194 

method of producing dry, 194 

method of preparing formulae 
containing dry, 195 
Milk depots, 61 

Milk laboratories, 155, 162, 182 
Milk modification, 154, 156- 
161 

apparatus for, 165 

home, 181 

cereal diluents in, 184 

conditions that control, 176 

cream in, 162 

Dr. Cumming's method for, 
154 

equipment for, 79 

lime water in, 157 

Dr. Rotch's method for, 154 

skimmed milk in, 159 
Milk, pasteurisation of, 150, 168 

in pasteuriser, temperature of, 
172 

recontamination of after com- 
mercial pasteurisation, 175 

taste of unaltered by pasteur- 
isation, 168 

commercial pasteurisation of, 
175 
Milk sugar graduate, 166 
Milk of magnesia, 256 
Milkmen, danger from, 148 
Milking, proper method of, 147 
Millon's reagent, 237 
Mineral matter in cow's milk, 

152 
Minimum amount of food, 197 



278 



INDEX 



Mixed feeding, 141 

Modification of amount of food, 

reaction of child to, 199 
Modification of cream, 163 
Modification of milk, equipment 

for, 79 
laboratories for, 155 
method of, 156 
necessary apparatus for, 165 
preparation of, 165 
conditions that control, 176 
home, 181 

of whey milk, 188-189 
Mongolian type of idiocy, 100 
Moral development and control 

of children, 218 
Morphine sulphate, 257 
Mortality, infant, 57 

infant, in various countries, 

57 
infant, causes of, 58 
infant, hot weather in cities a 

cause of, 58 
infant, reduction of, 58 
infant, variation in by months 

in New York, 59 
in breast fed babies, 60 
in infants fed on artificial 

food, 60 
infant, humidity a cause of, 60 
infant, illegitimacy a cause of, 

60 
infant, poverty a cause of, 60 
infant, in summer, 60 
infant, in private practice, 61 
of premature babies of differ- 
ent ages, 210 
Mother, duties of, 119 

illness of, a contra-indication 

to nursing, 120 
if properly instructed and con- 
trolled can nurse babies, 120 
care of nursing, 129 
diet for nursing, 129 
indications for weaning in, 

135 
menstruation of, no indication 

for weaning, 135 
treatment of during weaning, 

137 



Mouth, 8 

moisture of, 8 

at birth, 65 

cause of deformity of, 98 

method of examining, 226 
Mouth washing, 90 

danger of, 132 
Movements, method of obtaining, 
88 

offensive, 257 
Mucus, in feces, 86 

method of determining pres- 
ence of, in stool, 86 

respiratory in stools, 86 

in stool, cause of, 86 

in urine, 239 
Mumps, 250 
Murmurs, heart, 224 
Mustard, plasters, 258 

paste, 260 

Nap, 91, 107 

Nares, growth of post-, 37 

Nasal cavity, 8 

size of at birth, 8 

obstruction, an interference 
with sucking, 46 
Nasopharynx, importance of, 37 
Navel, infections, direction of, 5 

infection, 6, 64 

time of healing of, 6 

wound, 6 

care of, 64, 67 

dressing, 67 
Neck, 1 

lymph nodes of, 9 

size of at birth, 9 

stiffness of back of, 225 
Nephritis, 230 

blood in urine in, 232 
Nervous irritation, effect of, on 

breast milk, 129 
Nervousness of infants, 81 
Neurasthenia in infants, 81, 215 
Neutral fats in feces, staining 

for, 242 
Neutralisation of malt .extract 
by carbonate of potash, 192 
New born, anatomy of, 1 

baby, 12 



INDEX 



279 



New York State, infant mortal- 
ity in, 57 
Nicoll, Doctor, 46 
Nipple, cleansing of, 70 

abnormality of, 120 

cleansing of by infant, 129 

cracked, 135 
Nipples for bottles, 166, 176 
Nitrate of silver, 64 
Nitric acid test for albumin in 

urine, 234 
Nits, 225 

Nocturnal enuresis, 88 
Noise, disastrous effect of, on 
children, 81 

effect of on sick children, 81 
Normal child, control of, 218 
Nose, development of at birth, 8 

examination of, 226 
Nourishment, of child in utero, 1 

placental, 4 
Nurses, 81 

incompetent, 81 

necessary attributes of, 82 

trained nursery maids, 82 

wet, 138 

wet, as a final resort, 156 
Nursery, exposure of, 75 

hygiene, 75 

size of, 75 

ventilation of, 75 

fresh air in, 76 

ventilation, methods of, 76 

lighting of, 77 

arrangement of, 78 

artificial lighting of, 78 

furniture, 78, 79 

scales, 79 

table, 79 

walls, 79 

temperature, correct, 80 

isolation of from other parts 
of house, 81 

quiet in, 81 

should not be a sitting room, 
81 

situation of, 81 

fence, 94 
Nursery maids, trained, 82 
Nursing bottle, sanitary, 166 



Nursing, contra-indications to, 
119 
interference with by abnor- 
mality of nipple, 120 
inadequate, 127 
mother, care of, 129 
cracked nipple, 135 
pain in, 135 

stimulation of secretion of 
breasts by, 141 
Nutritional diseases not due to 

pasteurised milk, 168 
Nuttall, experiments on intes- 
tinal bacteria by, 51 
Nux vomica, 257 

Oatmeal, 185 
Obermayer's reagent, 237 
Odour, of feces, 87, 241 
(Edema due to eggs, 207 
Ophthalmia, 65 

cause of, 65 
Opium, 257 

dose of, 254 
Optimum of Von Pirquet, 198 
Orange juice, 104, 182 

amount fed, 182 

for artificially fed babies, 182 

as a preventative of scurvy, 
182 
Organs, lungs, solid, 4 

proportional weight of, 46 
Orphan asylum children, average 

weight of, 26 
Ossification of bones of skull, 34 
Otitis media, 248, 250 
Out of doors, time when baby 

should first go, 92 
Ovale, foramen, 2 

closing of, 4 
Oxidising ferment, 170 
Oxygen as a stimulant, 260 

Pail, proper milking, 147 

Pain in ears, 250 

Palate, cleft, an interference in 

sucking, 46 
Palpation of heart, 223 
of lungs, 224 



280 



INDEX 



Pancreas, 50 

amylolytic action of secretion 

of, 13 
at birth, development of, 13 
at birth, secretion of, 13 
secretion of, 50 
Pancreatic, secretion, action of, 
50 
extract, effect of on children, 
187 
Paregoric, 257 
Parotid glands, 225 
Pasteurisation of milk, 150, 168 
not a cause of nutritional dis- 
ease, 168 
not a cause of rachitis, 168 
not a cause of scurvy, 168 
temperature of, 170 
in nursing bottle, 171 
length of time that heat should 

be sustained, 172 
without use of apparatus, 171 
temperature of bottle of milk 
at 10°C. and one at 17°C, 
174 
commercial, 175 
Pasteuriser, 172 

directions for using, 172 
illustration of, 173 
Peculiarities of child at birth, 1 
Pediculi, 225 
Pelvis of infant, 1 

size of at birth, 10 
Pepsin, 13 
Peptone, 13 

Peptones, splitting up into amino 
acids, 50 
absorption of in intestines, 51 
Peptonising, 186 

effect on milk of long contin- 
ued, 187 
for premature babies, 214 
Percentage cream, 162 
Perception, cause of poor, at 

birth, 8 
Percussion, of abdomen, 223 

of lungs, 224 
Pericarditis, Roentgen-ray in 

diagnosis of, 246 
Petticoat, 68 



Pfaundler, Doctor, 48 
Pharyngitis during dentition, 43 
Pharyngeal cough, application 

for, 258 
Pharynx, examination of, 226 
Phenol, in urine, 231 
in urine, test for, 237 
in intestinal putrefaction, 257 
Phimosis, 96 

a cause of enuresis, 89 
Phosphates, amorphous, in urine, 
233, 239 
triple, 239 
in urine, 239 
Physical development, of chil- 
dren, 217 
Physical examination of chil- 
dren, 221 
method of making, 221 
of child while asleep, 222 
in diagnosis, 247 
Physician, friendliness of child 

to, 221 
Physiology of the new born, 12 
Physique, importance of good, 

216 
Pills, 252 

administration of, 254 
Placenta, 2 
Placental, blood, 2 

nourishment, 4 
Playgrounds, roof, 92 
Pneumonia, type common in in- 
fants, 9 
broncho-, 10 
lobar, 10 
pulse in, 222 
respiration in, 222 
Roentgen-ray in diagnosis of, 
245 
Pneumonia, 249 
Pneumococcus, thermal death 

point of, 169 
Pneumonic breathing, 248 
Poliomyelitis, 250 
Post-nares, growth of, 37 

size of, 37 
Poverty, a cause of infant mor- 
tality, 60 



INDEX 



281 



Poverty — Continued. 

use of breast milk for children 
born in, 118 
Powders, 252 
Pregnancy an indication for 

weaning, 135 

Premature babies, 210 

inactivity of, 211 

feeding of, 213 

cleansing of, 214 

Preparation of modified milk* 

165 
Prepuce, adherent, a cause of 

enuresis, 89 
Prescription for milk modifica- 
tion, 183 
Private practice, infant mortal- 
ity in, 61 
Proportions of infant body in 

comparison to adult, 5 
Proprietary foods, 195 

analyses of, 195 
Protein, transformation of in di- 
gestion, 13 
action of pancreatic secretion 

on, 50 
in breast milk, 70, 119, 123 
in colostrum, 71 
indigestion, curds an indica- 
tion of, 86 
deficiency of in breast milk, 

143 
in cow's milk, 151, 152 
caloric value of, 177 
indigestion, evidences of, 180 
milk, 190 
in feces, 242 
Proteolytic ferment, 170 
Pulmonary, arteries, 2 

orifice, stenosis of, 63 
Pulse, at birth, 12 

normal ratio of respiration at 

birth to, 13 
rate, 53 

rate, table of, 53 
in physical examination, 222 
in pneumonia, 222 
in diagnosis, 247 
Punishment, corporal, 219 



Pupils, equality of, 226 

reaction of, 226, 227 
Pus, in umbilical vein, 5 

in urine, 232, 238 

in ears, 250 
Putrefaction, intestinal, 231 
Pyelitis, 232 

bacteria present in urine in 
cases of, 232 

blood in, 232 

diagnosis of, 248, 250 
Pyloric spasm, 180 

stenosis, 181 

stenosis, vomiting in, 181 

Quantity of stool, 87 
Quiet, effect of on sick children, 
81 

in nursery, 81 

as a sedative, 257 
Quinine, 253 

Rachitis, evidence of, 34 
delayed dentition in, 43 
not caused by pasteurised milk, 

168 
physical examination for, 224 
cranio tabes in, 225 
Rash due to eggs, 207 
Raw meat juice should not be 
fed to babies, reason why, 
206 
Reaction, of child to modification 
of amount of food, 199 
to eggs by children, 207 
of urine, 233 
of feces, 241 
Reagent, Millon's, 237 

Obermayer's, 237 
Recording, results of certain 
tests of urine, 236 
the test for urine, 239 
Records, weight, importance of, 
27 
importance of height, 29 
of findings at birth, 65 
Rectal medication, 259 
Rectum, patent at birth, 65 
Red corpuscles, number at birth, 
14 



282 



INDEX 



Regime, daily, 102 

for baby under three months, 
102, 103 

from three to six months, 103, 
104 

for sixth month to first year, 
104, 105 

for second year, 105 

after second year, 106, 107 
Rennet, action of on milk, 187 
Respirations, 53 

at birth, 4 

number of at birth, 12 

regularity of at birth, 12 

normal relation at birth of 
pulse to, 13 

slower in sleep, 54 

table of, 54 

establishment of at birth, 63 

method of establishing, 63 

of new born, 67 

expiratory grunt, 222 

in diagnosis, 247 

conditions with normal res- 
pirations, 248 

conditions with rapid, 248 
Respiratory diseases in infants, 

9 
Rest, 91 

method of taking, 91 
Restlessness, 71 
Retraction, of foreskin, 65 

of head, 222 
Rewards and deprivations, 219 
Rheumatic, heart disease, 224 

decayed teeth a cause of, 91 

disease, 250 

symptoms, treatment of, 259 
Rhubarb, 257 
Rhythm of heart, 223 
Rickets (see rachitis), 168 
Rocking, 91 

Roentgen-ray, examination by, 
245 

in diagnosis, 245 

in diagnosis of tuberculosis, 
245 

in diagnosis of endocarditis, 
245 



Roentgen-ray — Continued. 

in diagnosis of pneumonia, 245 
in diagnosis of abdominal con- 
ditions, 246 
Roof, enclosures, 92 
extensions, 92 
protection of, 93 
Room, temperature of, 70 

especial for premature babies 
in hospital, 213 
Rotch, Doctor, 47, 155 

method for modification of 
milk advocated by, 154 
Roumania, infant mortality in, 

58 
Rusk, 204 

Russia, infant mortality in, 57, 
58 

Safety-pins as toys, danger of, 

84 
Salicylate of soda, 253, 259 
Saliva, 47 

first digestive fluid, 47 
in starch digestion, 47 
Salivary glands, development of 
at birth, 8 
power of secretion, to decom- 
pose starch, 13 
secretion of, 13 
time of increase of secretion 
of, 13 
Salol-splitting ferment, 170 
Salt, absorption of in intestines, 

51 
Salts, percentage in breast milk, 
71 
percentage in colostrum, 71 
in breast milk, 124 
in cow's milk, 151 
Sanitary nursing bottle, 166 
Sarsaparilla, syrup of, 253, 255 
Scales, 79, 121 
balance, 79 
receptacle for, 79 
spring, 79 

proper scales for weighing 
babies, 80 
Scarification, for vaccination, 111 
in treatment, 260 



L 



INDEX 



283 



Scarlet fever, 250 

Schmidt, fermentation test appa- 
ratus, 243 
test for undigested food in 
feces, 243 

School, 99 

age at which children should 

attend, 99 
interference of with nap, 107 
examination of children in, 

100 
periods for children of differ- 
ent ages, 216 
reason for slow progress in, 

216 
supervision of physicians over, 
216 

School children, average weight 
of 69,000, 26 

Schottilius, experiments on intes- 
tinal bacteria, 52 

Screens, cheese-cloth, as ventilat- 
ors, 77 

Scurvy, not caused by pasteur- 
ised milk, 168 
orange juice as a preventative 

of, 182 
blood in urine an indication 
of, 232 

Sebaceous glands at birth, 5 

Second day, care of infant dur- 
ing, 73 

Second year, diet for, 208 

Sedatives, 257 

Sediment of urine, 233 

Septic complications, weaning in, 
135 

Sex, sign of, 53 

Shininess of feces, 86 

Shirt, 68 

Shock, effect of, on breast milk, 
129 

Shoes, 95 

Sight of babies, 215 

Sigmoid flexure, length of, 49 

Silver nitrate, use of in eyes, 
74 

Sinus trouble, examination for, 
226 

Skeleton at birth, 6 



Skin, sebaceous glands of, 5 
irritation due to acidity of 

urine, 231 

medication, 259 

cod liver oil inunctions for 

dry, 260 

Skull, at birth, 6 

bones of, 6-7 

overlapping of bones of, 6 
compression of by tight ban- 
daging, 7 
deficient ossification of at 

birth, 7 
depression of bones of, 7 
membrane joining bones of, 7 
shape altered of, 7 
of infant at birth compared 
with that of adult, 35 
Sleep, voiding of urine during, 
56 
during first day, 70 
place for taking, 91 
necessary number of hours of, 

93 
character of, 222 
breathing during, 224 
Sleeping alone, 78 
Small-pox, vaccination for, 109 
Smegma, 96, 227 
Soda, bicarbonate of, 257 
Sodium salicylate, 253, 259 
Softness of stools, 87 
Solution, Benedict's, 235 

Fehling's, 235 
Soup, 204 

method of preparing, 204 
a substitute for meat juice, 
206 
Specific gravity of urine, 230 

measurement of, 234 
Specimens, of breast milk, method 
of obtaining, 122 
of urine, method of obtaining, 

229 
of feces, obtaining, 240 
Speech, age of beginning, 215 
Spinal column, 7 
curve of at birth, 7 
flexibility of, 7 



284 



INDEX 



Spinal Column — Continued. 

curvature, 7 
Spine, 34 

changes in, 36 
normal curves of, 36 
growth in length of, 37 
Spirillum cholerse Asiaticse, ther- 
mal death point of, 169 
Spleen, 45 

weight chart of, 38 
increase in weight of, 46 
enlargement of, 223 
Sprue, 226 
Sputum a conveyer of infection, 

97 
Standing, period at which chil- 
dren begin, 94 
Staphylococcus pyogenes aureus, 
128 
thermal death point of, 169 
Starch, power of secretion of 
salivary glands to decom- 
pose, 13 
digestion, saliva in, 47 
action of bile on, 50 
action of intestinal secretion 
on, 50 
Starvation, 128 
Sterilisation, of milk,. 168 

of beef juice, 206 
Stiffness of back of neck, 225 
Stools, colour of normal, 85 
quality of, 85 
colour of abnormal, 85-86 
importance of character of, 85 
clay-coloured, an indication of 

too much fat in food, 86 
dark colour due to bismuth, 86 
dark colour due to old blood, 

86 
dark colour due to iron, 86 
fresh blood a cause of red 

stain in, 86 
mucus in, 86 
shininess of, cause of, 86 
smoothness of, 86 
frequency of, 87 
hard an indication for more 

fat in food, 87 
loose, cause of, 87 



Stools — Continued. 

odour of, 87 

quantity of, 87 

softness of, 87 

time for procuring, 87 

method of obtaining, 88 

bad, in breast fed children, 
132 

(See also feces) 
Stomach, at birth, 10 

Form of, at birth, 10 

position of, at birth, 10 

at birth, fat-splitting ferment 
in, 13 

at birth, hydrochloric acid in, 
13 

at birth, pepsin in, 13 

a reservoir, 13 

tube, 44 

capacity of, 47 

capacity, importance of, 47 

capacity, methods of determin- 
ing, 47 

position of, 47 

shape of, 47 

capacity, table of, 48 

capacity, variations found by 
different investigators, 48 

wall, elasticity of, 48 

capacity, rule for, 49 

disturbance, 249 
Streptococcus, 128 

pyogenes, thermal death-point 
of, 169 
Strychnine, dose of, 254 

as a stimulant, 258 
Stimulants, heart, 258 
Steam inhalations, 260 
Submaxillary glands, 225 
Sucking, 46 

method of, 46 

a process of digestion, 46 

thumb, 98 

interference with, 119 
Sudan III, 242 

Sugar, absorption of in intes- 
tines, 51 

in breast milk, 70, 123 

in colostrum, 70 

in cow's milk, 151 



INDEX 



285 



Sugar — Continued. 

indigestion, evidences of, 180 
cane, as a substitute for milk 
sugar, 193 
Sugar of milk, graduate, 165, 
166 
not a clean product, 168 
Sugar in urine, 230 

tests for, 235 
Suggestion in control of chil- 
dren, 218 
Summer mortality of infants, 

60 
Suppositories, glycerine, 88 
Sweat glands, development of at 

birth, 5 
Sweden, infant mortality in, 58 
Syphilis, early dentition in, 43 
Hutchinson's teeth in, 43 
weaning in, 136 
blue ointment in, 260 
Syrup, as a medium in admin- 
istration of drugs, 253, 255 
of sarsaparilla, 253 
of Yerba Santa, 253 
Systolic murmur, 63 

Table of measurements, 254 
Tablets, 252 

administration of, 254 
Tache cerebral reaction, 228 
Tail, clipping of cow's, 146 
Teacher, proper for kindergar- 
ten, 99 
Tears, lack of, at birth, 8 
Teeth, 39 

(See also Dentition) 
development of at birth, 8 
period at which membrane is 

pierced, 8 
age at which first tooth ap- 
pears, 39 
eruption of at birth, 39 
age of eruption of first, 40 
age of appearance of second, 

41 
age of eruption of second, 42 
chart showing age of eruption 

of second, 42 
Hutchinson's, 43 



Teeth — Continued. 

rubbing through gum, 44 

care of, 90 

decayed, danger of, 91 

heart trouble due to, 91 

importance of care of, 91 

rheumatism due to decayed, 
91 

eruption of, 204 
Teething, disturbances of, 43 

(See also Dentition) 

Relief of symptoms by rubbing 
teeth through gum, 44 
Temperature, at birth, 12 

during dentition, 43 

of children, 53 

subnormal, 53 

of room for newly born in- 
fant, 70 

of nursery, 80 

of milk in pasteuriser, 172 

during pasteurisation of bot- 
tles of milk, 174 

record in diagnosis, 247 
Test, Holt's, 124 

Babcock, 126 

for quantitative acidity of 
urine, 233 

Schmidt fermentation, 243 

for acetone in urine, 236 

for diacetic acid in urine, 236 
Theory of infant feeding, 197 
Therapeutic measures, 255 
Thermal death point of bacteria 
in a moist medium, table of, 
169 
Thermometer, 80 
Thierfelder, experiments on in- 
testinal bacteria by, 51 
Thorax, small, 1 

circumference at birth, 6 

at birth, 65 
Threatening children, 218 
Thrill over heart, 63 
Thumb sucking, 98 

method for control of, 98 
Thymus gland, 9, 44 

(See also Gland) 

position of, 44 

weight of, 44 



286 



INDEX 



Thyroid extract in Cretinism, 

101 
Toast, 204 

Tongue, size of at birth, 8 
coating of, 226 
examination of, 226 
Tonics, 257 
Tonsil, third, 8 

third, seat of, 37 
Tonsils pharyngeal, 39 
Toys, 83 

articles to be avoided, 83-84 
dangers of, 83 
law regarding, 84 
as rewards, 219 
Training in order to procure 

movement of bowels, 88 
Treatment, 252 
Triple phosphate crystals, 239 
Trunk of infant, shape of, 5 

growth of, 30 
Trypsin, 186 
Tuberculin test for cows, 146, 

150 
Tuberculosis, in nursing mother, 
120 
weaning in, 136 
in cattle, 150 
bacillus, thermal death point 

of, 169 
susceptibility of babies to, 206 
Roentgen-ray in diagnosis of, 

245 
pulmonary, 249 
Tuberculous meningitis, 249 
Tumor of abdomen, 223 
Typhoid, immunisation, 115 
immunisation, reaction to, 115 
immunisation, number of ba- 
cilli injected, 115 
immunisation, interval be- 
tween injections, 115 
immunisation, time of im- 
munity, 115 
immunisation, method of, 116 
immunisation, time at which 
injections should be given, 
116 
bacilli in milk, 148, 149 
fever, 251 



Typhoid — Continued. 

inoculation, 260 
Typhosis, bacillus, thermal 
death -point of, 169 

Udders of cows, clipping of, 146 
Ulcerations in mouth, 226 
Umbilical, arteries, 2, 4 

cord, 2 

veins, 2 

vein, changes in, 4 

vein, pus in, 5 
United States, infant mortality 

in, 57, 58 
Uric acid infarctions at birth, 

10 
Urinary, analysis, 229 

tract, inflammation of, 232 
Urine, 54 

at birth, 13 

amount of, 13 

amount passed, 54 

specific gravity of, 13, 54, 56, 
230, 234 

daily secretion of, 55 

frequency with which it is 
passed, 55 

summary of amount secreted, 
55 

frequency of micturition, 56 

voided during sleep, 56 

voided when awake, 56 

poulticing of child with, 68 

passed in first days, 72 

normal excretion of in first 
twenty-four hours, 73 

in second day, 73 

habit in passing, 88 

obtaining specimen of, 229 

sugar in, 230 

phenol in, 231 

albumin in, 230 

dilution of, 230 

evidences of diabetes in, 230 

evidences of nephritis in, 230 

acidity of, 231 

acidosis, 231 

index of reaction to acetone 
and diacetic acid, 231 

indican in, 231 



INDEX 



287 



Urine — Continued. 
blood in, 232 
blood in, an indication of 

nephritis, 232 
evidences of pyelitis in, 232 
leucocytes in, 232 
pus in, 232, 238 
amorphous phosphates in, 233 
amorphous urates, 233 
colour of, 233 
colour of sediment, 233 
general appearance of, 233 
quantitative acidity of, 233 
reaction of, 233 
smoky, 233 

tests for albumin in, 234 
tests for glucose in, 235 
tests for sugar in, 235 
diacetic acid in, 236 
fermentation test for sugar, 

236 
test for acetone in, 236 
test for indican in, 237 
test for phenol in, 237 
bacteria in, 238 
blood cells in, 238 
casts in, 238 
ephithelial cells in, 238 
microscopic examination of, 

238 
ammonium urates in, 239 
calcium oxalate crystals in, 

239 
mucus in, 239 
phosphates in, 239 
recording the test for, 239 
urates in, 239 
bicarbonate of soda to alkalin- 

ise, 257 
urates in. 239 
Utero, nourishment of child in, 1 

Vaccination, 109 
definition of, 109 
time for first. 109 
virus for, 109 
site for, 110 
method of. Ill 
scarification for, 111 
time at which girls should 
have, 111 



Vaccination — Continued. 

contamination of, 112 

illustration of, 112 

protection of, 112 

evidence of taking, 113 

period at which it begins to 
take, 113 

revaccination, 114 
Vaccine inoculation, 260 
Valve, Eustachian, 2 
Vegetables, 207 

amount and kind that may be 
given in second year, 207 
Vehicles for medicine, 255 
Veins, umbilical, 2 

umbilical, in navel infections, 
5 
Vena cava, inferior, 2 

superior, 2 
Ventilation, 76 
Ventricle, contraction of, 2 

left, 2 

right, 2 
Vernix caseosa, 5 
Virus for small-pox vaccination, 

109 
Viscera, weight of, at birth, 11 
Vitality of infant at birth, 12 
Vocabulary of children, increase 

of, 215 
Vomiting, persistent, cause of, 
180 

in pyloric stenosis, 180 

due to eggs, 207 
Von Jaksch's disease, 249 
Von Pirquet, optimum of, 155 

charts of infant feeding, 197 

Walking for children, 94 
Warm baths as a sedative, 257 
Warm rooms no substitute for 

incubator, 213 
Washing of cows, 146 
Water, percentage in breast 
milk, 71 
percentage in colostrum, 71 
dirty, a cause of illness, 97 
dirtv, a source of contamina- 
tion, 149 
in cow's milk, 151 



288 



INDEX 



Weaning, 134 

time for, 118, 134 
indications for, 134 
indications in child for, 134 
loss in weight, an indication 

for, 134 
disease in mother not always 

an indication for, 135 
indications in mother for, 

135 
menstruation no indication for, 

135 
pregnancy an indication for, 

135 
in septic complications, 135 
method of, 136 
in syphilis, 136 
in tuberculosis, 136 
treatment of mother during, 

137 
Weighing, baby, proper scales 

for, 79 
the baby, time for, 91 
before and after nursing, 121, 

142 
Weight of infant at birth, 5, 16 
proportion of vitality to, 12 
relation of length to, 15 
as a standard of development, 

15 
charting of, 15 
gain in, 16 
loss of, 16 
loss of in first few days' of 

life, 16 
at one year, 16 
at second year, 16 
stationary, 16 
rate of gain of, 19 
failure to gain in, 24 
of older children, average gain 

in, 24 
variation in normal, 24 
of boys and girls, comparison 

of, 27 # 
a guide in convalescence, 27 
an indication of illness, 27 
record, importance of, 27 
growth in length of children 

who do not gain in, 30 



Weight — Continued. 

of organs in infancy and child- 
hood, 38 

of heart, increase in, 44 

of lungs, 45 

proportional, of organs, 46 

loss of in first few days, 121 

failure to gain, 127 

loss of, an evidence of inade- 
quate feeding, 127 

gain in, even with bad stools, 
132 

gain in, on dextrinised cereal 
decoctions, 186 

effect on, of withdrawal of 
food, 198 

of eight month baby, 210 

of premature babies of differ- 
ent ages, 210 

of foetus in utero, 211 
Weight chart for first week, nor- 
mal, 16 

of first year, normal, 18 

individual, 19, 21 

variation in average, 22 

average weight chart of first 
year of children under vari- 
ous conditions, 23 

with normal lines, 24 

showing that loss of weight is 
an important indication of 
approaching illness, 28 
Wet nurses, 138 

necessity for, 138 

objections to, 138 

control of baby of, 139 

examination of, 139 

selection of, 139 

diet of, 140 

as a final resort, 156 

reason for employing, 195 

for premature baby, 214 
Whey, 153, 187 

elements of, 187-188 

milk, difficulty of preparing, 
188 

milk, modification of, 188- 
189 

use of in cases of colic, 188 
Widal reaction, 115 



INDEX 289 

Words, age at which babies first Yerba Santa, 255 

use, 215 syrup of, 253 

Worms, intestinal, 251 Young's formula of dose of drugs 
Worry, effect on breast milk, 129 for children, 253 

a cause of inadequate breast 

milk, 143 Zweibach, 204 

X-Ray, 245 

( See also Roentgen-Ray. ) 



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